Version imprimableOver the last fifty years, few public health professionals have considered Marxism relevant, and few Marxists have treated pandemics as an imminent concern. We offer this paper to help both public health professionals and socialists view pandemics through a Marxist lens. Although our theory is global in scope, we focus on the U.S. because of its scientific prominence, its outsized global role in the AIDS pandemic, and its poor performance in the COVID-19 pandemic. Our hope is that this piece will strengthen efforts to protect public health and, better yet, help usher capitalism off the Earth before it makes the planet uninhabitable.
Two pandemics
HIV/AIDS and COVID-19 have killed tens of millions since 1980. Both probably began in transmission from an animal to a human. [1] Yet, due to their dissimilar modes of human-to-human transmission and differing intervals between infection and serious illness, they were met with distinct political responses: COVID-19 became a major global crisis while the response to HIV/AIDS was limited. COVID-19 threatened profitability by spreading rapidly through the global working and capitalist classes. In contrast, HIV/AIDS spread much more slowly, primarily affected poor countries, and in richer countries mainly affected highly stigmatized populations.
Despite these differences, the responses to the two pandemics also bear similarities. Both were prone to controversies about their severity, nature, and treatment. Ronald Reagan and Thabo Mbeki downplayed the seriousness of HIV/AIDS; Donald Trump and Jair Bolsonaro’s ideas about COVID-19 alternated between dismissive and bizarre. Joe Biden’s administration, including the Centers for Disease Control and Prevention (CDC), has minimized the COVID pandemic’s severity and overestimated the effectiveness of efforts against it. [2] In both pandemics, popular and elite ideologies have significantly contributed to disease and death, including HIV denialism (mainly affecting South Africa), dismissal of antiretroviral therapy in preventing AIDS, and the “anti-vax” and anti-masking movements throughout the COVID-19 pandemic.
A Marxist approach to analysing responses to pandemics
Marxism views human society in a dialectical relationship with its environment, including pathogens like viruses and their various host species. Capitalist society is structured by nation states, which vary in political form, ideology, economic strength, imperialist relations, degree of class conflict, and natural environment. Thus, during pandemics, capitalists and politicians scramble to protect their own health and the health of their national workforce insofar as they estimate that working-class health is necessary for profit production. They impose policies that ensure workers remain productive and do not revolt.
Moreover, earlier responses to pandemics have material and ideological effects. For example, neoliberal restructuring made the U.S. “lean” in trained personnel and protective equipment, while prior SARS-CoV-1 experience led many Asian countries, even poorer ones, to have ample mask supplies and mask-wearing experience. [3]
At the beginning of any pandemic, little is known. Scientists and politicians make decisions based on prior epidemics. As knowledge accrues, including which populations are most affected, it shapes the beliefs and actions of the capitalist class, the state, and sections of subordinated classes. Thus, in the mid-1980s, when a generalized heterosexual AIDS epidemic emerged in some African countries, U.S. elite fears helped generate resources to prevent sexual spread from people who injected drugs to those who did not. Once it became clear that a general epidemic was unlikely in the U.S., programs and policies for people who injected drugs became more limited. Early in COVID-19, workers in meatpacking and hospitals were the primary victims, alongside the elderly, institutionalized populations, Black, Native American, and Hispanic people. When this became obvious, politicians began to relax mandatory controls. Those closest to industries threatened by “science” (like fossil fuel producers) moved to discredit the science behind COVID-19 restrictions regardless of the cost in “disposable” populations’ lives.
A note on ideologies and irrationality
At capitalism’s ideological core is the self-interested individual who bears primary responsibility for their own fate. Modern capitalist ideology also emphasizes top-down management, which leads firms and states, including public health agencies, toward bureaucratic implementation. Capitalism is also characterized by racist and sexist beliefs that are fully institutionalized and normatively controlling.
Since conflicts over science and anti-scientific policy-making were important in both the HIV/AIDS and the SARS-CoV-2/COVID-19 pandemics, it is important to discuss Marxist ideas about the social sources of irrationality. Karl Marx and Frederick Engels discussed these issues primarily in relation to religious beliefs. Sam Friedman, co-author of this article, has also written usefully on this topic. [4]
Thus, the chaos of capitalist production generates chaos and mystification in the lives of workers and other oppressed or exploited groups. For example, the wage form is inherently mystified. Eschatological beliefs grow as capitalism’s leaders evidently cannot solve its most profound crises such as climate change and nuclear armed imperial competition.
Racism, which is foundational to capitalism, though strategically rational for the capitalist class, is fundamentally irrational because it interprets the effects of oppression as its causes. [5] Mistaking effect for cause is irrational by definition.
Capitalism’s inherent irrationality underpins contingent irrationalities, such as the anti-science sentiment seen during the HIV/AIDS and COVID pandemics. [6] Irrationalism is often strengthened by the self-serving actions of specific capitalist sectors. [7] For example, tobacco and agricultural interests have attacked research that reveals the harmful effects of their products. Fossil fuel industries have disputed climate change science despite climate change threatening general capitalist profitability and human survival. As evidence grows that capitalism can’t solve the climate crisis, doomsday religions and anti-science have strengthened.
The U.S. response to AIDS
Historical timing fundamentally shaped the U.S. response to the HIV/AIDS pandemic. Although HIV had been spreading in the country for at least seven years, it wasn’t politically and medically visible until 1981. [8] By this time, popular movements such as the Black revolt, the student and antiwar movements, and the rank-and-file-based labor unrest of the 1960s and ’70s had been largely defeated. [9] Ideologically and politically, deregulation and the celebration of self-interest become hegemonic thanks to the successful employers’ offensive embedded in the Jimmy Carter and Reagan administrations’ policies, and strengthened by the “Volcker Shock” when the Federal Reserve hiked interest rates while cutting back social funding, leading to massive increases in unemployment. [10]The impact was compounded as corporations moved industrial jobs to the non-unionized U.S. South, Latin America, and Asia. [11] This, along with the Drug Wars, facilitated right-wing demagoguery in splitting communities even further by class, race, and sexuality to reduce resistance to neoliberalism. [12] Hence, when the HIV/AIDS pandemic emerged, policies were so individualistically focused, so stigmatizing of queer people, drugs users, and sex workers, that essential research and care were delayed for years and, when prevention was even attempted, it was hamstrung, resulting in untold deaths.
Although HIV/AIDS spreads much more slowly than COVID-19, its death count during the early 1980s quickly mounted. Neither mass media coverage nor state-funded research followed. Randy Shilts’s book And the Band Played On shows that neither the CDC nor the National Institutes of Health (NIH) received additional funding for AIDS after the pandemic was discovered in 1981, and that the 1977 Legionnaires outbreak in Philadelphia and the Tylenol poisonings in 1982 both received far more attention and money than AIDS. [13]
As affected groups discovered they were high risk, media and government neglect forced communities to raise pandemic awareness and undertake their own prevention and mutual aid efforts. [14] Stop AIDS in San Francisco and the Gay Men’s Health Crisis in New York were two early examples of such efforts.
To the extent the federal government did respond, it primarily focused on biomedical and clinical research, case data surveillance, and, to a limited degree, epidemiologic research using existing agency funding. By 1986, some attention was given to public education around viral transmission. These efforts immediately sparked controversy, with powerful reactionary forces insisting that gay existence remain taboo, that sexual education be euphemistic, and that drug users become abstinent.
Overwhelmingly, epidemiologic and prevention programs were based on individual behavior. [15] This is congruent with basic ideology in capitalist society, as reinforced by the NIH’s and CDC’s reliance in non-biological prevention on randomized controlled trials that focus on individual characteristics. [16] Public health agencies and AIDS NGOs are normally top-down, hierarchical organizations that staff projects with grant funding. [17] Therefore, when the CDC finally funded large-scale prevention projects, its awardees were educational institutions, local and state governments, and NGOs intervening on individuals rather than their social environments.
There were exceptions. Notably, in 1986, when fear of widespread heterosexual transmission was still prevalent in the U.S., the first major NIH prevention program for people who inject drugs allowed community-focused outreach and evaluation using community indicators of infection rates. However, as worries about heterosexual transmission subsided, the NIH reoriented toward individual-level data.
Meanwhile, non-state and non-NGO community-driven projects focused on group activity, which saved lives. Buddy systems helped the sick care for themselves at home and manage pets during hospitalization. Stop AIDS in San Francisco built communal “Tupperware parties” where gay men discussed the pandemic. Later, ACT UP protested AIDS policy, organized independent research, and coordinated syringe exchanges alongside volunteers and organizers within drug-injecting communities. Despite immense pressure, significant community-based prevention prevailed. [18] Sterile syringe exchanges were particularly effective. Data from New York City show that once these originally underground services were legalized and funded, they greatly reduced HIV transmission among people who inject drugs. [19]
Through the late 1980s and ’90s, NIH HIV/AIDS research funding increased, partly due to political pressure and direct action by ACT UP and harm reduction groups, leading to breakthroughs in the treatment of opportunistic infections like pneumocystis carinii pneumonia and cytomegalovirus. By 1996, this politically won research led to effective antiretroviral therapy (ART), which kept the disease under control for most patients and reduced viral loads and thus infectiousness, leading to large-scale declines in HIV transmission throughout the U.S. Under pressure from mass demonstrations in South Africa and international activists, the World Health Organization and major foundations began providing ART to the world’s poorest countries despite pharmaceutical patents. In 2003, the U.S. established the President’s Emergency Plan for AIDS Relief, which significantly funded ART and related services globally, while increasing corporate and U.S. influence over drug sourcing and governing rules.
These programs were somewhat successful in providing effective safer sex and drug use education, and in controlling the HIV pandemic despite continuing attacks on LGBTQ people and those who inject drugs. By 2012, U.S. leaders were forecasting “the end of AIDS.” This optimism proved misplaced on both national and global levels. ART funding was inadequate to end AIDS in the Global South. Currently, transmission in the U.S. hovers around 35,000 new cases per year. Combatting climate change will increasingly drain volunteers and funding for HIV prevention and care efforts. [20] The COVID-19 pandemic led to further attenuation of resources.
The US response to COVID-19
COVID-19 arrived under conditions quite distinct from those under which the HIV/AIDS pandemic began. The employers’ offensive that had begun a half-century earlier had weakened unions, privatized state expenditures, globalized production and finance, and deeply entrenched ideological individualism, creating social tensions and general misery. Nonetheless, capitalist domination was running into resistance and sometimes revolt. Working-class misery led to political revolutions such as those in Argentina in 2002, and in a number of Arab countries and Ukraine after the 2008 economic crisis. Working-class organizing and resistance increased in the U.S. during the 2010s despite the ongoing erosion of labor unions. By 2020, years of antiracist organizing crescendoed in the George Floyd protests, a massive uprising against police violence during the first summer of COVID-19.
Capitalist politics, meanwhile, became polarized, often causing congressional deadlocks and impeding responses to the COVID pandemic. Reactionary movements, including armed racist militias, gained influence inside and outside the establishment. Some capitalists and others attacked climate science, while other factions attempted to coopt antiracist movements and apply “market-based” responses to climate change.
Successive “drug epidemics” like crack and then opioids led to an ever-rising number of overdose deaths. By the start of the COVID-19 pandemic, overdose deaths were approximately 80,000 a year; by 2021, they were nearly 110,000. Intensifying this crisis, neoliberalism drastically cut public health jobs. There were 220 public health workers per 100,000 people in 1980; by 2014, that number had dropped to 93. [21]
Then COVID-19 appeared. Neoliberalism’s gradual hollowing of public health and medical resources, compounded by vacillating and incompetent presidential and state leadership, led the U.S. into a preventable spiral of viral spread, disease, and death. [22]
Source: Our World in Data.
An edited volume on Coronavirus Politics provides detailed accounts of the first few months of the response. [23] Accurate COVID testing was available in other countries months before the CDC was able to produce and distribute tests in the U.S. The initial partial lockdowns came too late. In some states, the initial lockdowns were ended far too early, leading to massive additional spread. Even governors who received initial acclaim for smart policies did not grasp the basics of aerosol transmission and therefore could not help high-risk locations or slow community transmission. [24] In both New York and New Jersey, for example, this led to catastrophic numbers of nursing home deaths. Relatedly, when the CDC established reporting systems as a basis for surveillance and understanding the epidemiology of SARS-Cov-2 transmission, it originally failed to include race/ethnicity and never included information about workplaces. (Much of what we know about workplaces is due to the California surveillance system and outbreak investigations.) [25]
Despite rapid vaccine development, nations overlooked strategizing how to organize the roll-out to curb viral escape mutation, instead prioritizing their own populations’ short-term protection. Poorer countries waited months or years for vaccines for working populations, likely fueling the deadly global spread of the delta variant.
However, vaccine roll-out would have been unlikely to succeed anyway due to well-heeled opponents, such as Robert Kennedy Jr., scion of the Kennedy dynasty, who seized the opportunity to promote half-truths and cherry-pick data from unvetted papers, and political entrepreneurs like Ron DeSantis, who attacked life-saving measures as ineffectual and anti-business. [26] Though initiated by President Trump, he and his followers also weakened the vaccine roll-out by promoting dangerous therapies like bleach, hydroxychloroquine, and azithromycin. [27]
COVID-19 has disproportionately infected and killed racially oppressed people (Native American, Black, and Hispanic people especially), the elderly, institutionalized populations such as prisoners and nursing home residents, workers in particular industries and occupations, and the disabled: populations that capitalists routinely disdain. Elderly people do not usually create surplus value for capitalists. Capitalists assume institutionalized people and disabled people do not create surplus value, and thus capitalist spokespeople often depict them as disposable drains on government budgets and pension funds. The immiseration of racially oppressed people reinforces racism and its structures among white workers and others. [28]
Unlike HIV/AIDS, COVID seriously threatened ruling-class members, politicians, and their workforces. Governments thus initially enacted lockdowns, which created a severe global economic slump that could have threatened the socioeconomic stability of capitalism. Countries responded in ways that reflected preexisting local social welfare infrastructure and traditions, which produced multiple contradictions. First, capitalism depends on workers’ need to seek a wage for survival and for social respectability. Without this need, businesses and governments would face labor shortages and a potential increase in strike action. Income support policies weaken this compulsion, which is why welfare systems inadequately address need and stigmatize recipients. [29]
Second, working from home allowed workers to reflect on their lives. This threatened the availability of labor power if too many workers resisted returning or contemplated capitalism and how to end it. [30]
Early in the pandemic, the U.S. federal government provided direct income support (though much less than other Organization for Economic Cooperation and Development countries), and extended unemployment insurance to many who would not normally have been eligible. Federal eviction moratoria were enacted to stop the spread of COVID-19 and to keep workers healthy for future exploitation. State enforcement of eviction moratoria varied considerably, so landlords were able to execute nearly 280,000 evictions in 2020. [31]
The system’s ability to maintain such supports over the long term was limited, in part by international and intranational competitive pressures. Thus, reopening took place unevenly among the various states and became highly politicized, both in the sense of partisan politics as well as in terms of interpersonal debate and movement politics.
Working people were divided. They wanted to keep themselves and their families and friends healthy. Yet, stay-at-home policies and school closings reduced their sense of human connection. Worry for their children’s future economic prospects, coupled with the hassles and pleasures of spending time with their children, pulled working-class individuals in opposing directions, creating openings for factions of the capitalist class and political entrepreneurs to divide the working class against itself, weakening working-class self-defense.
When Biden took office in 2021, his administration faced the competing demands of COVID-19 prevention and capitalist profitability. It immediately extended welfare supports and emphasized vaccination, testing, and masks, arguing: “If we raise our vaccination rate, protect ourselves and others with masking and expanded testing, and identify people who are infected, we can and we will turn the tide on COVID-19.” [32]
He required large employers to give paid time off for required COVID vaccinations. However, he did not require bosses to offer paid sick leave, ensuring that many workers would still have to go to work infectious. Biden then emphasized a policy of “keeping our children safe and our schools open,” including the vaccination of (eligible) children and school staff. He mentioned testing, masking, and adequate ventilation systems, but never made a plan to implement them. [33]
Despite the weakness of these policies, by November 2021, the administration was already undermining them further. [34] In addition to capital’s needs, partisan politics in the run-up to the midterms was a contributing factor. Republicans were successfully mobilizing their base around opposition to vaccines and mask mandates—and capturing some on the anti-vax left along the way.
In December 2021, the CDC changed its recommendations for isolation from ten days to five. [35] This change did not reflect epidemiologic findings, nor the advice of expert scientists and clinicians. As Rob Wallace has shown, this reduction was a reaction to government and industry concerns that the pandemic had decreased the workforce willing to accept current pay levels. The aim was to resume in-school education, making parents more available as workers, and was influenced by intense lobbying from the airline industry. [36]
Next, the CDC changed how it measured COVID risk itself. In February 2022, the CDC changed its “transmission map,” based on new COVID-19 diagnoses and positive tests, to a “community levels map” focused on hospital capacity. Overnight, the CDC’s map went from a concerning red, showing substantial risk nationwide, to a reassuring green. [37] The effect was to permanently discourage masking nationwide. [38]
Opposition to masking is now deeply entrenched government policy. For example, when the CDC director, Raquel Walensky, warned about the “tripledemic” of influenza, respiratory syncytial virus, and COVID-19 in October 2022, she refused to suggest masking, even under public criticism, for two months. [39] Despite high COVID-related sickness and mortality, the uncertainty of ongoing SARS-CoV-2 mutations, and long COVID’s impact on the labor force and population, the capitalist class and state remained committed to a “return to normal” to restore profitability. They ended the pandemic emergency and its social provisions in spring 2023.
Caught between, on the one hand, fear of disease, death, and long COVID’s economic threat, and, on the other, the allure of human companionship and workplace ambition, the “return to normal” campaign has gained broad public acceptance even among groups hardest hit by the pandemic. Whether this acceptance will continue despite continuing deaths and the spread of long COVID depends on several contingencies: Will the virus mutate toward greater severity? Will new vaccines and therapies control its spread? Will public health and community groups, like the People’s CDC or Long COVID Justice, successfully counter the capitalist state’s callous disregard? Could economic collapse, or a resurgence of class struggle, antiracist struggle, feminist struggle, and/or disability rights struggle, undermine the capitalist state’s credibility? Could semi-fascist forces enforce capital’s ideological conformity to “the urgency of normal”?
Neoliberalism’s gradual hollowing of public health and medical resources, compounded by vacillating and incompetent presidential and state leadership, led the U.S. into a preventable spiral of viral spread, disease, and death.
Discussion
Neither pandemic is over. HIV continues to infect, sicken, and kill. Current funding commitments suggest that the limited control achieved over the AIDS pandemic may falter. The powerful “anti-vax” movement will be a hurdle to distribution of any effective HIV vaccines that should be discovered, compounding the longstanding problem of profit-driven vaccine research on a disease that affects the poor.
The COVID-19 pandemic is also far from over. Vast numbers of people sicken and die from it—and long COVID is a mass disabling event. As this paragraph is being written, the People’s CDC, an invaluable resource for understanding how to respond to the pandemic from a socially involved public health perspective, stated in their weekly “Weather Report” that “at least 3,907 people died of COVID nationally.” [40]
We are likely to experience more major pandemics. [41] Capitalism puts humans into contact with viruses and bacteria through constant business, military expansion, and travel. Capitalist industrial agriculture forms a perfect breeding ground for viral and bacterial mutations, as evidenced by frequently emerging new varieties of avian and swine flu. Careless over-prescription of medicines to get workers back on the job and to increase meat production accelerates the development of bacteria and viruses that medicines can then no longer cure.
Pandemics, then, happen more rapidly and spread far more rapidly than they did in earlier historical eras due to advanced capitalist production and distribution. Science under capitalism has, to be sure, provided new ways to try to counteract these dangers. But the history of the responses to HIV/AIDS and COVID-19 shows that the needs of capital and the states that serve capital hamstring our ability to respond to pandemics. The COVID-19 response history indicates a major defeat for those favoring “public health” approaches to pandemics that prioritize worker protection over “opening up.” Capitalist interests skeptical of pandemic and climate change science have successfully reduced executive authority for health emergencies and opposed vaccination and masking rules. This retreat suggests Democrats and Republicans will prioritize immediate economic profitability over public health in future pandemics.
Some public health response limitations to pandemics stem from firms’ profit interests, evident in government support for intellectual property rights. This has enhanced profits for HIV antiretroviral therapy and COVID-19 vaccine makers, leaving billions poorly protected and millions dead. Fortunately, these “rights” are firm-specific, so they can be challenged without total opposition from capital, as when the global efforts of AIDS movements enabled additional firms to produce generic HIV antiretrovirals that let millions of people get them more cheaply.
By the beginning of 2022, capitalists decided that vaccination provided sufficient protection against devastating declines in labor power availability for behavioral protections to be ended and employees who had worked from home to be forced to work at their workplaces. [42] Politically, this developed in part out of (perceived) advantages in productivity and in workplace control from opening up, and in part due to the existence of a lot of people who disliked wearing masks.
Our argument in this piece helps to understand China’s COVID policies. One partial reason why China opened up was that its approach was creating a significant competitive disadvantage when other countries opened up. Specifically, regular city-wide lockdowns in 2022 were hindering Chinese capital’s ability to ensure prompt product delivery to both domestic and international customers. In the era of global neoliberal just-in-time production, supply chain disruptions from these lockdowns were fueling inflation and undermining Chinese capital’s competitiveness. Amid escalating inter-imperialist tensions and U.S.-led diplomatic offensives against China, this disadvantage risked becoming debilitating. When worker revolts against the zero-COVID approach erupted at Foxconn and elsewhere, paralleled by university and street demonstrations, China’s rulers opted for global opening up. The subsequent COVID-19 outbreak has been significant, but likely not enough to substantially weaken China’s economy.
In essence, 2022 saw a global decision by capital and state leaders to risk workers’ health and lives to maintain competitive standing. This gamble is fraught with uncertainty. The dynamics of long COVID, which incapacitates many workers, remain unclear. Depending on virus mutations and worker responses, this mass disabling event could become more prevalent and economically—and perhaps militarily—debilitating. Capitalists are also gambling on being allowed to let the virus run rampant without workers rising up and threatening to end the system itself. [43]
Pandemics present a dilemma for capital: it must balance public health measures to preserve the labor force for future exploitation against letting workers sicken and die for immediate exploitation. COVID-19 is unique in that capitalists initially chose to protect workers’ health, leading to issues like massive production decline, enduring supply chain shortages, inflation, and worker strikes, partially offset by the significant income increase for billionaires and major corporations during the period of worker self-protection. [44]
The lessons from HIV/AIDS and COVID-19 are vital for public health and global populations, especially as neither pandemic is waning, and capitalism’s dynamics will prompt future pandemics. Moreover, these pandemics coincide with escalating climate change disruptions. Massive global migrations induced by climate change will inevitably accelerate disease spread, including HIV/AIDS and SARS-CoV-2/COVID-19, while simultaneously disrupting the capacity to manage pandemics.
We underscore the need to eradicate capitalism and establish a new social order rooted in revolutionary democracy, where workers sustainably organize the production and distribution of necessities and thereby prevent mass pandemics. Just to add to the difficulty, we will need to do this “on the ashes of the old” —that is, while dealing with the catastrophes of global climate change, the pandemics capitalism spawned, and whatever disorganization and destruction takes place in the struggle to end capitalism. [45]
For now, we must remember that the way to total transformation—that is, a social and ecological revolution—is through mass movements that struggle for reforms in ways that build workers’ power and their consciousness of their power. Such struggles require a thorough understanding of the ways in which racial, gender, and other oppression can create new forms of mobilization and struggle, and can develop new ideas and proposals of how we will organize a new society. The historical memory of the caring communities and hard-won infrastructure built by groups like ACT UP and Stop AIDS is an invaluable lesson in how to respond to health emergencies with solidarity and people-centered programs, not austerity and profit-focused individualism.
The historical memory of the caring communities and hard-won infrastructure built by groups like ACT UP and Stop AIDS is an invaluable lesson in how to respond to health emergencies with solidarity and people-centered programs, not austerity and profit-focused individualism.
We in public health must collaborate with workers and communities affected by pandemics, including movements like those against AIDS and COVID, that demand sensible public health and social policies from the state. In doing this, we must fight for class independence and recognize that both capitalist political parties are obstacles to our collective survival.
