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JAMA Forum
December 9, 2021

Reckoning With COVID-19 Exceptionalism

Author Affiliations
  • 1School of Public Health, Boston University, Boston, Massachusetts
JAMA Health Forum. 2021;2(12):e214854. doi:10.1001/jamahealthforum.2021.4854

The COVID-19 pandemic is an ongoing tragedy, resulting in more than 5 million deaths worldwide since it emerged—becoming the third leading cause of death in the US in 2020—and bringing about immense economic and social disruption. Commensurate with this tragedy has been an extraordinary focus on the disease in the media and in scientific work. By May 2020, 10 000 articles about COVID-19 were published and indexed in PubMed, with an average of nearly 100 articles added every day.1 Well over 100 000 articles were published about COVID-19 in 2020, or about 6% of all articles indexed in PubMed. In a short time, COVID-19 has become a “first among equals” among diseases; some journals saw a doubling in the number of submissions received, driven by COVID-19–related papers.

As the effects of COVID-19 grew, and commensurate attention was paid to the disease in scientific publishing and in the public and political conversation, the efforts to contain COVID-19 and the dedication of resources to it were complicated by increased mortality and morbidity from a range of diseases. In 2020, across a range of high-income countries, approximately 1 million excess deaths were reported, well exceeding mortality from COVID-19.2 In the US, there was a 20% increase in mortality, not all of which was linked to COVID-19.3 Deaths from some diseases reached record highs. For example, there were more than 93 000 deaths from drug overdoses in the US, exceeding 2019 deaths by more than 25%, and becoming the largest single-year increase in more than 2 decades.

All of this suggests that as we near the end of the second year of the COVID-19 pandemic, it is important to think about how we recalibrate and how we think of COVID-19 in the context of other diseases around us, as well as how to optimize both scholarship and the attention of the health system to the full range of threats to health. History had demonstrated that disease exceptionalism can be both a blessing and a curse. HIV exceptionalism in the US was responsible for galvanizing attention to the disease, changing policy, and creating funding conditions that vastly accelerated our ability to deal with a deadly infectious disease.4 Globally, however, it also contributed to a narrowing of focus and a fragmentation of health care systems.

Although there is good reason to argue that the continued special focus on HIV is warranted, given the ongoing scope of the pandemic’s consequences—more than 680 000 people died from AIDS worldwide in 2020—it is also true that the global burden of a broad range of other diseases receive substantially less attention, sometimes as a consequence of the focus on HIV/AIDS. By way of example, in some contexts high AIDS awareness may result in tuberculosis patient delay;5 more than 1.5 million people died from tuberculosis globally in 2020, making tuberculosis the second leading infectious disease killer globally, right after COVID-19, and well ahead of AIDS. Moreover, as the World Health Organization notes in a recent report, 2020 marked the first time in a decade that tuberculosis deaths increased—stemming from reduced access to tuberculosis diagnosis and treatment because of the COVID-19 pandemic.

This leads then to the question: how does the biomedical community reckon with the place COVID-19 should take in its efforts going forward, maintain focus on a disease that continues to contribute to a substantial global burden of morbidity and mortality, but also use this attention on a single disease to achieve positive results while minimizing the potential adverse consequences of doing so?

First, a single-minded focus on COVID-19 in scholarship, intellectual thought, and orientation of health systems simply cannot continue. The surges in the deaths from other public health problems—such as opiate overdoses in 2020—were truly terrifying and require us to refocus and pay suitable attention to these issues. This suggests the need for deliberate recalibration, scaling back some of the attention to COVID-19 through funding and programmatic work, and ensuring that other diseases are the focus of scientific and medical attention commensurate with their burden.

Second, the challenge with any instance of disease exceptionalism is to make sure that funding and efforts help in finding long-term solutions that deal not only with that disease, but also with others like it. The focus on HIV helped galvanize science, served as a reminder that infectious diseases in general were not gone forever, and helped give rise to a generation of infectious disease researchers who were among those at the forefront of the COVID-19 response. Similarly, the biomedical community can start shifting away from a dominant focus on COVID-19 to infectious diseases more broadly—in particular, airborne infectious disease—to create a generation of scholars and clinicians who are skilled in studying and treating these diseases.

Third, the medical community needs to recognize that COVID-19’s consequences have unfolded as they have because of underlying social and economic injustices that predisposed many to a disproportionate burden of COVID-19 as a novel coronavirus. This means using the COVID-19 moment as an opportunity to shift the conversation about the underlying conditions that create health, away from the notion that it is only about the coronavirus. HIV exceptionalism served to spark movements that elevated justice-based approaches into the collective consciousness, transforming care received by, for example, LGBTQ populations. COVID-19 exceptionalism will be a success only if it can lead similarly to a reckoning with the factors that resulted in the COVID-19 burden among minoritized racial and ethnic groups, for example.

We cannot sustain any single disease-based exceptionalism forever. The question is how to extract from a single-minded focus on 1 disease the benefits that can extend more broadly to create health in the long-term. Even though we are still in the throes of the COVID-19 pandemic, funding and publishing practices, once established, develop substantial inertia, making changing focus difficult. This suggests that for the biomedical community, it is well worth being deliberate about the attention it is paying to COVID-19 and, as importantly, attending to other diseases that threaten the health of populations in the coming years.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Galea S. JAMA Health Forum.

Corresponding Author: Sandro Galea, MD, DrPH, Boston University, 715 Albany St, Boston, MA 02118 (sgalea@bu.edu).

Conflict of Interest Disclosures: Dr Galea reported serving as a board member for Sharecare.

Odone  A, Galea  S, Stuckler  D, Signorelli  C; University Vita-Salute San Raffaele COVID-19 literature monitoring working group.  The first 10 000 COVID-19 papers in perspective: are we publishing what we should be publishing?   Eur J Public Health. 2020;30(5):849-850. doi:10.1093/eurpub/ckaa170PubMedGoogle ScholarCrossref
Islam  N, Shkolnikov  VM, Acosta  RJ,  et al.  Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries.   BMJ. 2021;373(1137):n1137. doi:10.1136/bmj.n1137PubMedGoogle Scholar
Woolf  SH, Chapman  DA, Sabo  RT, Zimmerman  EB.  Excess deaths from COVID-19 and other causes in the US, March 1, 2020, to January 2, 2021.   JAMA. 2021;325(17):1786-1789. doi:10.1001/jama.2021.5199PubMedGoogle ScholarCrossref
Smith  JH, Whiteside  A.  The history of AIDS exceptionalism.   J Int AIDS Soc. 2010;13:47. doi:10.1186/1758-2652-13-47PubMedGoogle ScholarCrossref
Ngamvithayapong  J, Winkvist  A, Diwan  V.  High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area, Thailand.   AIDS. 2000;14(10):1413-1419. doi:10.1097/00002030-200007070-00015PubMedGoogle ScholarCrossref
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