March 18, 2020
Translated by Karen Pinkus, Editor of Diacritics
There has been a good deal of important writing by Italian intellectuals during the lockdown there. A short piece by Giorgio Agamben, titled “The Invention of an Epidemic,” has aroused a great deal of controversy. It was followed by another titled “Contagion,” which begins with a quotation from Alessandro Manzoni’s The Bethrothed, also cited in the piece I just translated, by Felice Cimatti. Elettra Stimilli, whose writing on faith and debt will appear in our next issue, posted another important reflection, “Being Together at a Distance.” And so on. I’ve been in touch with a lot of Italians over the past two weeks and it’s hard not be inspired by their creativity, generosity, and good humor. I’m writing this from Cambridge, where the weather is pleasant and the mood is calm (with an underlying anxiety, no doubt, as we are being told that we can expect “mass deaths” as we wait for “herd immunity” to kick in). Cimatti’s essay seems to me to be an important reflection from the front lines and I find it comforting to know that we can still think. There will be more to come.
The Metaphysics of Patient Zero
Metafisica del paziente zero, by Felice Cimatti, first published in Italian on March 9, 2020, on Fata Morgana Web.
During the first days of the epidemic in Italy there was a lot of discussion of the so-called patient zero. Now (I am writing this on Saturday, March 7, 2020) the frenzy of this discussion has died down a bit except for the occasional nod, made perhaps with a certain malignant satisfaction, to other nations. Patient zero, it is said, the person who carried the virus to Europe, may have been German. Obviously, it changes nothing, at the medical or economic level, if this patient zero is German or Italian. The only thing that interests me, a complete non-expert in matters of virology, is what remains unstated in the very use of the term “patient zero.” On first utterance, the term seems to refer to the person with whom the infection begins. The unstated assumption of the expression “patient zero” is precisely that before this poor individual fell ill, there was no trace of the infection. In essence: before, everything was fine.
“Patient zero,” then, signifies the passage from an originary condition of health to a subsequent condition marked by illness. The precise point of passage between these two conditions is embodied in patient zero. In this sense, patient zero is less a concrete or real figure than a metaphysical operator, someone who interrupts the normal state of health and carries with(in) himself the exceptional state of illness. It is precisely for this reason that it is important to locate this individual because if he can be identified, one might hope to trace his movements and contacts and block further contagion. Obviously, I’m not referring here to the medical procedure of pinpointing hotspots. My point is not physiological. I’m interested in the idea that we all have, or that we would like to have, that there is an essential difference between a normal state and state of exception. And it’s precisely because the concept of patient zero allows us to imagine an interruption of normality that he has to exist. Only if we can identify him can we continue to believe that without him, life would have gone one as normal.
Here in Italy it’s become a cliché these days to refer to The Betrothed, the 1827 historical novel by Alessandro Manzoni. For better or worse, almost every schoolchild in Italy has heard about the plague in Milan during the seventeenth century and it’s hard not to think about Manzoni’s spreaders or poisoners (untori) these days. It’s not that the spreader really exists. Rather, it’s necessary that he exists, otherwise the plague—as a disruption of normal life—would be incomprehensible. Sickness has to be the exception: “At the first intelligence of a new comer,” Manzoni writes, “at the cry even of a child, the alarm bell was rung; and the unfortunate persons were assailed with showers of stones, or seized and conducted to prison.” It’s not just a question of the logic that one who seeks something finds it but more accurately that we have already, unconsciously, made up our minds that it will be found.
So what or who is patient zero” really? Here it’s important to distinguish between the so-called index case and the primary case.” “Primary case” refers to someone who introduces an infection into a given social group, for instance, a schoolroom or the emergency room of a hospital. “Index case,” on the other hand, refers to the first patient known to medical authorities in a certain location. It’s not a given that these two cases coincide in the same person. On the contrary, it’s more likely that they do not. As the Swedish epidemiologist, Johan Giesecke, writes, in most epidemics doctors never learn the identity of the “primary case.” But putting aside medicine and turning to philosophy, we can reformulate the distinction in this way: the “primary case” regards ontology, that is, the real constitution of the world; the “index case,” on the other hand, regards gnoseology, that is, our possible and limited knowledge of the world. The “index case” is much more common, but our ontological prejudice wants it to be not just conceptual but material. It wants “index case” and “primary case” to be synonymous.
The idea of “patient zero,” which is in fact more journalistic than scientific, is the collapse of this fundamental distinction. In this sense the primary case does not seem all that far from the spreader of The Betrothed: in both cases the goal is to find some person “responsible” for an infection. But medicine, like all forms of scientific inquiry, only deals with index cases” It is only with the index case that medicine can formulate prevention or cure. To cite the Paduan virologist Giorgio Palù, from an interview with the online journal Il Bo Live:
The diffusion of the virus is no longer a question of importation from a foreign body. It now has a self-perpetuating, endogenous life. The virus has become well adapted to humans, perhaps for longer than we know, and it is also transmitted by asymptomatic carriers; so, there is no more point in looking for patient zero.
But what does it mean to say “there is no more point in looking for patient zero”? This question is not about medicine, as I noted, but about something unstated, hidden in the concept itself. In this sense, the impossibility and even the inutility of finding that which we might call the “primary case” means that the infection was there before we were aware of it (“index case”), that is that in some way it always existed just like the number zero (0), the natural positive numbers (1, 2, 3, …) and the whole negative numbers (-1, -2, -3, …). So, if we admit that “patient zero” exists, just as 0 is a whole number, then also “patient -1” and “patient -2” must also exist. And so on. The infection was always there in any case. But this means that the very distinction between a normal, non-infected state and a state of exception a, of infection, is put into question.
Life is all about such lack of distinction. Moreover, the fact that this discussion has developed around a virus is especially interesting since for biology, a virus is “a sort of limbo between the living and the non-living.” In effect, a virus seems made to order to problematize neat distinctions: on the one hand it is composed of a protein sack (capside) that contains genetic material, DNA or RNA. On the other hand, a virus can live and reproduce only by infecting a living cell. It contains the essence of life, genetic material, but it is not itself properly alive. Yet “viruses are important for life: they constitute the constantly shifting border between the biological and the biochemical spheres.” They are not alive but they are essential for life. Maybe it’s no coincidence that an idea that spreads quickly is said to become “viral.”
So what does it mean to say that patient zero does not exist as such? It means that there is no absolute beginning, that is, that the beginning has always already begun, just as the end will never cease to end. To indicate this condition, Jacques Derrida developed his concept of différance:
Essentially and lawfully, every concept is inscribed in a chain or in a system within which it refers to the other, to other concepts, by means of the systematic play of differences. Such a play, différance, is thus no longer simply a concept, but rather the possibility of conceptuality of a conceptual process and system in general.
Thought begins when patient zero is none other than the transfer between patient -1 and patient +1. To think is to not fear this transfer. On the contrary, patient zero is precisely the negation of thought, that is, a thought that is limited to finding the spreader, that is, a being—possibly non-existent—in which thought can finally rest, complacent and self-satisfied.
 Alessandro Manzoni, The Betrothed (London: Richard Bentley, 1834), 378.
 Villarreal, “I virus sono vivi?,” 9.
 Jacques Derrida, “Différance,” in Margins of Philosophy, trans. Alan Bass (Chicago: University of Chicago Press, 1982), 11.