Pandemic explores conditions that generate pathogenic microbes and the pathways through which they become contagious and spread widely in human populations. In thinking and writing about recent emerging pathogens through the lens of the established ones—cholera, especially—which were quickly transmitted and killed a large number of people in less advanced societies, Shah began tracking the origins of pathogens in Port-au-Prince, the wet markets of China, and the surgical wards of New Delhi. At first glance, the book may lead readers—from advanced countries, especially—to the conclusion that pathogenic microbes, which are capable of causing outbreaks in epidemic proportions, originate from areas where relatively low standards of living are widespread. However, it becomes apparent as one reads further that today’s advanced countries harbor conditions conducive for the production of pathogenic microbes and do not differ as much as we might think in this regard from the places Shah began the inquiry. Clearly, we are safer than poorer countries, but far from immune. For readers curious about the various ways contagious disease take root and spread, Shah’s Pandemic provides a persuasive set of explanations. The book is an excellent introduction for academics teaching contagion globally, and for experts and administrators seeking to effect lasting public health impact on the ground.
Pandemics are hugely, sometimes apocalyptically, destructive. For instance, plague pandemic in the 14th century contributed to the collapse of the global trade system, which linked many parts of the world and was strongly rooted in the Middle and Far East. The pandemic, known then as Black Death, was directly responsible for labor shortages and political instabilities in areas where the trade was concentrated. There is the view that it is impossible for outbreaks of plague, cholera, and other contagions to occur in advanced countries—where standards of living are pretty high—as they did in past societies. The view sounds plausible enough on the surface, considering current advances in biomedicine and strict codes for housing, provisions for sanitary water for domestic use, effective waste management, and highly developed public health administration connected to a vast educational system. Undeniably, the advances in biomedicine and public health were exceedingly effective in preventing deaths and epidemics in the 20th century. And because of that, the varied conditions enabling pathogenic microbes to transform from one stage to another until they result in pandemics are more easily detected and combated against than they were before the 20th century. Shah states, however, that biomedicine is restricted by reductionism, that is, a sort of tunnel vision about treating an outbreak without considering the broader social and physiological context and meaning of the outbreak, and by our public health system that is slow and passive.
… it becomes apparent as one reads further that today’s advanced countries harbor conditions conducive for the production of pathogenic microbes and do not differ as much as we might think in this regard from the places Shah began the inquiry. Clearly, we are safer than poorer countries, but far from immune.
Shah reminds readers that improvements in public health, which followed the emergence of flush toilets and modern indoor running water, are far from complete, foolproof, and equal. The incident of a cholera-stricken patient whom Shah almost boarded a flight with from Port-au-Prince in Haiti to Fort Lauderdale in Florida explains just how fast cholera could have crossed national boundaries: a native traveler goes from one country with woefully inadequate public health infrastructure to another possessing very good facilities but brings that inadequacy with him or her as a subject of that infrastructure. The narrative casts my mind back to the danger of open drains and public toilets, which I saw during my last three years of fieldwork in Accra and Nairobi—two populous capital cities in Ghana, West Africa and Kenya, East Africa. In the event of a cholera outbreak in one of those cities, the pathogen is just a flight away from New York, London, or Paris. Perennial floods in these cities carry filth—including human and animal excreta—from open drains and public toilets into homes. During flooding, the intimacy of drains and public toilets, the widespread exposure to improperly treated and contained human waste, pose a public health threat that is linked internationally.
On a daily basis, in urban areas, the interaction between the wealthy, who enjoy first-class sanitary amenities, and the poor from overcrowded areas with meager municipal services and inadequate sanitary infrastructure, is considerable—much more than many might think. In Nairobi for instance, the wealthy residing in Lavington and Westlands employ domestic help from Kibera and other popular settlements in the city. The help move from their homes to their employers’ residents and perform wide-ranging duties, cleaning, cooking and taking care of infants. This means that during an epidemic, pathogens from Kibera will reach Westlands and Lavington within hours. It is hoped that these scenarios moderate the indifference of residents in wealthy countries and upper-class residential areas in cities where people believe cholera affects only the poor. Wealthy residents of 19th-century modern and prosperous Paris, London, New York, and New Orleans thought so too. But when cholera struck, it killed both wealthy and poor.
The narrative casts my mind back to the danger of open drains and public toilets, which I saw during my last three years of fieldwork in Accra and Nairobi—two populous capital cities in Ghana, West Africa and Kenya, East Africa. In the event of a cholera outbreak in one of those cities, the pathogen is just a flight away from New York, London, or Paris.
Why cholera is the thematic cornerstone of Pandemic is based on the assumption that the next pandemic to strike humanity will resemble the characteristics of cholera: before victims—and indeed public health authorities—know of the contagion, vast number of people would have been infected and victims would be nearing death in a ghastly manner before any sort of effective treatment can reach them or even be devised for them. Shah’s opening narrative clearly illustrates the sequence. Cholera was extremely contagious and inspired tremendous fear and panic. Following cholera’s example, the next pandemic is named “cholera’s child.” Today, of course, cholera does not inspire dread as it did in the 19th century and earlier. When it flooded in Accra and Nairobi during the time I was collecting archival materials, there was hardly any mass outcries or hysteria about a cholera epidemic in the cities, despite the fact that some people got sick with cholera. But public panic in Nairobi following Ebola outbreaks in Guinea, Liberia, and Sierra Leone—in West Africa—in 2014 led to talks of stringent preventive measures, including a ban on flights to and from West Africa. Newspaper publications, aimed at pushing the government to ban flights to the affected regions, showed how Nairobi’s Jomo Kenyatta International Airport could be the gateway for Ebola spread in East Africa.
Shah demonstrates how fears drove politicians and public health authorities—both within and outside Africa—to adopt strict preventive measures, which actually impeded the fight against Ebola. They initiated very harsh quarantine measures, canceled flights to and from affected countries, and banned travels to Ebola-stricken countries. Meanwhile, widespread panic led to increased demand for biohazard suits. In the midst of the confusion and anguished cries from affected countries for international support, there were no available flights for aid workers to reach the stricken, and supplies of biohazard suits were quickly depleted. There was much fear and hysteria in the United States despite public health experts asserting that the chances of Ebola spreading in the country were very slim. But state and public health authorities instituted very strict quarantine measures. My experience of the reaction to Ebola in the United States was very personal. Several weeks after arriving in the United States from doing field work in Nairobi in late August 2014, I was feeling sick and called Students Health Services (SHS) at Washington University in St. Louis. I requested to see a doctor immediately because it was an emergency. I had returned from a farm with friends. I became sick several days after returning from the farm. In a telephone conversation with a nurse, I provided detailed information of where I had been in the last three months. The nurse suspected Ebola—because I had been to Africa—and induced panic and fear before my arrival for treatment.
To Shah the reason for the indifference to some contagions such as cholera and the serious concerns about others such as Ebola is the feeling that the former had been conquered and latter has not been. The flush toilets, running water, and the other physical manifestations of the “sanitary revolution”—vis-à-vis privies and latrines in 19th-century Europe and America—together with life-saving treatments for cholera put the contagion in the category of vanquished infections, much like smallpox, which was eradicated through a vaccine. This cannot be said of Ebola. Shah argues that this attitude of categorization of contagion indicates how humanity would respond to the next pandemic.
One reason some contagions do not inspire fear and sometimes lead to indifference is the unfettered confidence people have in biomedicine. Shah narrates a personal experience to underscore the limits of biomedicine. When Shah contracted MRSA (methicillin-resistant Staphylococcus aureus) and went to see doctors, none of them considered other factors—including location of residence, immune status, and diet—that could have been responsible or facilitated the infection. They targeted just the pathogen, prescribing hosts of treatments, like sterile pads, tape, antibiotic cream, and drawing salve. For three years, Shah struggled with the infection despite continuous treatments. Eventually, Shah gave up. When another bump appeared and Shah ignored, it disappeared. That happened again and again. Why that happened, Shah was not sure. Although Shah had scores of theories in mind: adjustment of the immune system? the countervailing action of another strain of MRSA? diet? exercise? or the latent effect of the treatments? If the reason for the disappearance of the bumps had nothing to do with these theories, Shah was still certain it was more than the treatments the doctors provided. Doctors focused solely on treating the infection, and suggestions on preventing the pathogen from crossing over from one household member to another was not a priority.
The reductive approach of biomedicine manifests also in non-collaboration with veterinarians and social scientists. Yet it is established firmly that pathogens jump from animals to humans. Chimpanzees and apes in parts of Africa had long been infected with Ebola before it appeared in humans. Social and economic factors also contribute to pandemics. A rash of foreclosures in Key West—and other parts of South Florida—in 2008 led to abandoning of swimming pools and gardens. Mosquitoes bred abundantly in abandoned areas and caused the dengue fever outbreak in 2009. Shah is declaring the necessity of collaborative work among biological scientists and other experts across disciplines in order to rise above the limitations of a purely biomedical view of pandemics. Coupled with the fact that the pathogenic microbe that would cause the next pandemic currently exists in our environment and lurks among the human population, Shah’s suggestion is persuasive.
Biomedicine aside, added to the uneven availability of flush toilets, running water, and other sanitary facilities, the public health “revolution” in the 20th century does not make provision for other fecal matter other than human excreta. Dog excrement in gardens, parks, yards, and on streets also pose a health threat to the public. The excrement mixes with soil, “wafts into the air, and washes into waterways,” contaminating the environment. When the mixing takes place, the excrement teams up with pathogenic microbes such as E. coli, and roundworms. Dog excrement is responsible for about a third of contaminations in U.S. waterways and causes parasitic infections in residential areas where dogs are common.
By identifying and explaining clearly the limits of biomedicine and the gaps in our public health system, Pandemic brings to the fore far-reaching lessons for public health, state, and municipal officials who are obligated to deal with the next contagion. Talks of an impending pandemic and beliefs about a coming pandemic in themselves are very frightening. We are reminded of the mass hysteria which followed the Ebola and SARS outbreaks in the recent past and how unnerved large populations can become when faced suddenly with the reality of humanity’s vulnerability to mass sickness. For students and academics reading and doing histories of diseases, talk and rumor of a large-scale outbreak of disease sharpen the imagination, making more vivid the horrors of past cholera and plague outbreaks. And Shah’s analysis of these fears and how they affect how any given society would respond to future outbreaks is very interesting.
Shah does not conclude without suggesting ways the next pandemic might be managed. Shah states that because of inevitable shifts going on in the environment, pandemics are unavoidable. But they can be detected quickly and prevented. To do that, there is a need for an enhanced surveillance by private organizations, state agencies, academic institutions, and the World Health Organization in places where contagious diseases are likely to emerge. Some of the disease hot spots include slums, factory farms, busy airports, and places attracting or containing wild animals. Also, simple and effective universal healthcare, as well as trained health-care workers to recognize and report pathogens, are required. Sustained search through medical data, social media, and other online sources for signs of disease outbreaks will help detect and prevent the next pandemic from spreading far and wide.
A sensitive issue in Pandemic that requires extended discussion is the fallout of the cholera outbreak in Haiti and how Shah handles it. Human rights lawyers were holding Nepalese soldiers—stationed in Haiti by the United Nations—responsible for pouring fecal matter in a river from which many people drank and used for domestic purposes. The Haitian human rights lawyer, Mario Joseph and his counterparts in America were trying to establish the complicity of the United Nations, demanding reparations and an apology in U.S. and European courts. Is the action of the lawyers and the 15,000 Haitians—whose signatures the lawyers collected—reducible to scapegoating or fixing blame? How do we understand the Haitian case in a way that would help in dealing with the next pandemic? People unknowingly do carry pathogens. Healthcare workers in Guinea (2014), gay people in (1980s), and Irish immigrants in New York (1930s). Are they to blame? Shah is troubled by that. Understandably, local conditions—such as local sanitary and public health infrastructure—are as responsible for the cholera outbreak as external influences. And it is hard to determine how much blame carriers, like the Nepalese soldiers, should shoulder. The problem with scapegoating is that it tends to weaken “social ties and exploit” political divisions in a variety of ways. It makes cooperation between groups more difficult, which is essential in the prevention of pandemics.
… it is hard to determine how much blame carriers, like the Nepalese soldiers, should shoulder. The problem with scapegoating is that it tends to weaken “social ties and exploit” political divisions in a variety of ways. It makes cooperation between groups more difficult, which is essential in the prevention of pandemics.
But reducing Joseph’s complaints to scapegoating and equating them to varied cases in different places and at various times blur very complex factors. The quotes from Joseph allude to issues of class and race, which also deserve consideration outside the brackets of blame. Rather than weaken social ties and political institutions and ultimately impede concerted efforts against pandemics, a holistic understanding of Joseph would facilitate the work at nipping the next pandemic-causing pathogen in the bud. Would the United Nations have been more careful selecting troops if they were being stationed in the U.S., Europe, or Canada? Would the Nepalese soldier(s) who poured fecal matter in the river have done so if they were stationed in these advanced countries? Consideration of both the ramifications and the justification of Joseph’s complaints would mend the cracks in social ties and political divisions rather than widen them. Shah’s interpretation of Joseph’s position on the cholera outbreak in Haiti also raises questions of how academics, journalists, and other researchers represent their interview respondents. Because quoting selectively provides readers a partial, even biased glimpse, a more rounded interpretation would be more useful.
A book this wide-ranging glosses over specific and local factors as it does with the points Joseph raises. Since the spread of pathogens is heavily dependent on interaction of people, especially across the boundaries of disease environments, Pandemic should be, but is not, an example of how to do long-range historical comparisons of the spread of contagion drawing on such significant political or social instances as Roman imperialism, the European conquest of the Americas, and the spread of Bantu-speaking Africans on the continent. For instance, did Bantu-speaking Africans deliberately introduce pathogens as war strategy against populations that had no immunity? How is that comparable to Roman imperialism and the European conquest of the Americas? What is being blurred in the consideration of these events that occurred across space and time is agency and changing knowledge of diseases and conditions of transmission. Which is why teachers and experts interested in understanding the local context and effecting meaningful transformation need not only read the Pandemic and its rich reference list, but also consult outside materials not listed in the book’s bibliography.
Since the spread of pathogens is heavily dependent on interaction of people, especially across the boundaries of disease environments, Pandemic should be, but is not, an example of how to do long-range historical comparisons of the spread of contagion drawing on such significant political or social instances as Roman imperialism, the European conquest of the Americas, and the spread of Bantu-speaking Africans on the continent.
Pandemic shows that while we cannot prevent pandemics altogether from occurring, there are mechanisms to ascertain the chain of conditions under which microbes become pathogenic and transmit across large human populations. Shah’s Pandemic will provide very useful explanations to readers interested in understanding how our transforming relationship with microbes is being affected by climate change, globalization, and industrialization. Pandemic also shows the effects of politics and social relations in facilitating or forestalling outbreaks of contagions. The book covers scores of contagious diseases including bubonic plague, influenza, smallpox, and HIV. It also has visual representations, including maps on the flu pandemic; cholera outbreaks in New York City, London, and Port-au-Prince; and pictures of conditions that generate contagion.