Pandemic Non-fiction: What you don’t know can kill you

There is no shortage of books about diseases through human history, but a few have become definitive classics. I’ve curated an admittedly highly opinionated selection of the best. Some books that arguably would have qualified have been left off simply because they are too old, and medicine changes so rapidly that it could be misleading to include them.

The Coming Plague: Newly Emerging Diseases in a World Out of Balance by Laurie Garrett. (Farrar, Straus and Giroux, 1994).

One of the nation’s leading health science reporters, Laurie Garrett has won nearly every major prize in journalism, including the Pulitzer, Polk (twice) and Peabody. This book in 1994 was her assessment of how the infectious disease research community was motivated by the AIDS crisis to try, mightily, to warn the world.

Where the book excels is in telling of the people literally risking their lives to do research, such as an American team of experts who did field work in 1963-1964 to discover what was behind Bolivian Hemorrhagic Fever, catching and barely surviving the disease themselves. In the 1950s, there was a worldwide effort to stamp out malaria by using the pesticide DDT, which in Bolivia killed enough cats to allow mice to run rampant, carrying a different and deadlier disease into the human population.

A German-Jewish doctor in 1974 being driven in a van with his patient, another German doctor extricated from Nigeria with deadly Lassa fever, ridiculously imagines that they are being taken to a secret concentration camp where they will all be disposed of and their deaths will be blamed on the disease. Lassa virus proved so dangerous that research at Yale University had to be ended because its biosafety laboratory precautions were insufficient to protect staff.

By 1975-1976, the little town of Lyme, Connecticut, was where a new tick-borne disease was discovered; it infects 300,000 each year in the US. Legionnaire’s disease was discovered because of an outbreak in 1976 at an American Legion convention, but we now know it causes about 13,000 severe cases a year, although it might never have been discovered but for that outbreak.

More recently, the 1990s emergence of a novel hantavirus strain in the American West, a deadly pathogen that often kills otherwise healthy young people, inducing acute respiratory distress syndrome (ARDS) with a ferocity similar to First World War poison gas such as phosgene and phosphene, demonstrates the threat is current. Hantaviruses had been studied since the 1980s, apparently migrating from Korea to infect virtually the entire population of rats and mice in US cities, likely contributing to higher rates of hypertension and kidney disease among the urban poor – at the same time federal and state funding dried up for rodent control programs. Western state members of Congress pushed through an emergency $6 million response to the 1990s epidemic; Garrett notes, “Some members of Congress remarked that such an allocation might not have been necessary if DoD budget cutters hadn’t gutted the Army’s hanta program two years earlier.”

No book better summarizes the 20th century effort to fight infectious disease, especially with enormous successes such as the elimination of polio and smallpox begun in the 1950s and expanded aggressively throughout the world in the 1960s and 1970s, and then taking the reader on a grand tour through the development of genetic engineering, widespread drug resistance, refugee migration, political instability, increasing inequality in health care between the first and third worlds, loss of diversity among plants and animals, ecological consequences of massive deforestation, ocean pollution and global warming. The book even presciently predicts the emergence of what we know today as the opioid crisis and the effect of opposition to needle exchanges.

The closing theme of the book is a warning that the threat from infectious disease is very much still with us, using as an example an international war game scenario in Honolulu in 1989 that shocked all participants, uncovering a universal lack of readiness among all government, military and international organizations. Half of vaccine manufacturers withdrew from the business by 1990 because it was insufficiently profitable. The World Health Organization (WHO) is widely regarded as so underfunded and politically hesitant that one researcher noted AIDS was already on four continents before they recognized it. As governments abandon attempts to detect new diseases, non-governmental organizations such as Médecins Sans Frontieres (Doctors without Borders) have come to fill that role without any clear mandate, planning or funding. The only organization with the expertise and funding to manage global surveillance of infectious disease, the consensus seemed to be, the US Centers for Disease Control and Prevention (CDCP). But, of course, this was written in 1994 before decades of further budget cuts.

Garrett, as recently as January 31, 2020, published a devastating criticism, “Trump Has Sabotaged America’s Coronavirus Response,” in Foreign Policy: “For the United States, the answers are especially worrying because the government has intentionally rendered itself incapable. In 2018, the Trump administration fired the government’s entire pandemic response chain of command, including the White House management infrastructure. In numerous phone calls and emails with key agencies across the US government, the only consistent response I encountered was distressed confusion. If the United States still has a clear chain of command for pandemic response, the White House urgently needs to clarify what it is – not just for the public but for the government itself, which largely finds itself in the dark.”

The Great Influenza: The Epic Story of the Deadliest Plague in History by John M. Barry. (Penguin, 2004).

President George W. Bush read this book on vacation and it made such an impression that as soon as he was back in Washington he handed it to his top homeland security adviser. “‘You’ve got to read this,’” she remembered him telling her. “He said, ‘Look, this happens every 100 years. We need a national strategy.’” Bush started an effort to prepare to make vaccines, stockpile medical equipment such as masks and ventilators, and establish a global early warning system to detect new diseases. In a 2005 speech to the National Institutes of Health, Bush said, “A pandemic is a lot like a forest fire. If caught early it might be extinguished with limited damage. If allowed to smolder, undetected, it can grow to an inferno that can spread quickly beyond our ability to control it.”

Barry focuses not on the politics and consequences of the 1918 pandemic, but on the science: Many of the crucial techniques that allowed real science and research to be done toward understanding the virus in a modern way had been invented only a few years earlier, so those who found themselves scrambling under enormous time pressure were working at, and often expanding upon, the cutting edge of biological science. Decades before the discovery of antibiotics or the genetic structure, using techniques that seem primitive today, they worked methodically and carefully to piece together what they could of the puzzle. Even the idea that influenza itself changed over time, often quite rapidly in what we now know to be genetic mutation, was a radical idea that faced substantial opposition.

In his prologue, Barry writes: “Shortly before the Great War began, the men who so wanted to transform American medicine succeeded. They created a system that could produce people capable of thinking in a new way, capable of challenging the natural order. They, together with the first generation of scientists they had trained… formed a cadre who stood on alert, hoping against but expecting and preparing for the eruption of an epidemic. When it came, they placed their lives in the path of the disease and applied all their knowledge and powers to defeat it. As it overwhelmed them, they concentrated on constructing the body of knowledge necessary to eventually triumph. For the scientific knowledge that ultimately came out of the influenza pandemic pointed directly (and still points) to much that lies in medicine’s future.”

What is most striking about this book is that it emphasizes how the 1918 pandemic came just as medicine was moving from an unscientific past – many doctors still believed in the “miasma theory” that diseases such as influenza resulted from “bad air” rather than concrete germ pathogens – into a recognizably modern future. As their understanding of the immune system improved, they experimented with ingenious methods such as “antiserum,” extracting what we would now call antibodies from the blood of recovered patients and injecting it into newly ill patients. In the absence of a vaccine, this remains one of the best approaches available, and it is being used today for COVID-19.

The strength of the book is that it well conveys the genuine excitement of science, even describing century-old work: “All real scientists exist on the frontier. Even the least ambitious among them deal with the unknown, if only one step beyond the known. The best among them move deep into a wilderness region where they know almost nothing, where the very tools and techniques needed to clear the wilderness, to bring order to it, do not exist.”

America’s Forgotten Pandemic: The Influenza of 1918 by Alfred W. Crosby. (Cambridge University Press, 2nd ed. 2003).

The 1st edition was published under the title Epidemic and Peace: 1918 by Greenwood Press in 1976, coincidentally as the world prepared for a swine flu pandemic that never materialized. As the author explained in the preface to the 2003 2nd edition, “it seemed to be a piece of medical antiquarianism, informative and interesting, I hoped, but with little immediate relevancy.”

Conventional medical opinion had by the 1960s concluded that infectious diseases would fade as threats relative to those of middle and old age such as high blood pressure, heart disease and cancer. The 1970s swine flu fizzle reinforced this assumption. It was the discovery of AIDS, caused by human immunodeficiency virus (HIV), that in the 1980s refocused attention on infectious diseases, creating such demand for Crosby’s book that Cambridge University Press acquired rights and reprinted it in 1989, 1990 and 1997. As the rate of new infectious threats continued to increase, Crosby expanded the book in a 2nd edition to take account of Asian flu and SARS-1. He died in 2018 at age 87.

A masterful and detailed history, the first 200 or so pages are effectively the lead-up, the evidence gathering, for a strongly critical assessment: The politicians and public health officials in the 1918 pandemic, which came in repeated waves of receding and resurging until 1920, took a very long time to understand what was going on around them and even longer to respond to it. We still don’t know how many died a century ago from that pandemic, and credible estimates range from a low of 20 million to a high of 100 million worldwide. If you’re curious about this sort of thing, Crosby will tell you on page 215 that there were 3,328 “excess deaths” in Rhode Island from September 1918 to June 1919, and on page 217 that 1,416 of them were in Providence. As I write this on May 2, COVID-19 has killed 296 in Rhode Island over three months. The distinctive characteristic of the 1918 pandemic, that it was unusually lethal for people 20 to 40 years old, fortunately is not seen in COVID-19.

In the end, Crosby somewhat throws up his hands: “Can we have another killing pandemic of influenza? We don’t really know what happened in 1918, and so we cannot justify optimism… It is wiser to be humble than arrogant about influenza.” Of greatest resonance to us today is that Crosby closes his book with a chapter titled “An Inquiry into the Peculiarities of Human Memory,” noting that proposals into the 1920s and 1930s to undertake a serious effort to study and prepare against infectious disease came from members of Congress, state governors, medical societies, insurance companies and newspaper columnists, all of which went nowhere: “Studying the record of the American people in 1918 and 1919 is like standing on a high hill and watching a fleet of many vessels sailing across a current of terrible power to which the sailors pay little attention. They grip their tillers firmly, peer at their compasses and hold faithfully to courses, which, from their vantage, seem to be straight, but we can see that the secret current is sweeping them far downstream. The immense flow swamps many of the ships and their sailors drown, but the others take little notice. The others are intent on maintaining their own unwavering courses.”

Why Trust Science? by Naomi Oreskes. (Princeton University Press, 2019).

One of the leading writers on the political controversies of science, Oreskes (with Erik M. Conway) in 2010 published Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming (Bloomsbury Press).

Everyone knows there are delusional anti-vaccine activists who distrust science, but even those who do trust it may not have a much better understanding.

This philosophy book grew out of the Tanner Lectures on Human Values at Princeton University in November 2016, where Oreskes gave two lectures, responded to by four commentators, with subsequent reply by Oreskes, all brought together in this volume. The goal is to examine how science works, how scientists do science, what happens when scientists get things wrong, and why the overall process is ultimately trustworthy. Science is a collective endeavor that seeks critical consensus, and we can learn from mistakes ranging from eugenics to dismissal of subjective reports by women of depression correlated with hormonal birth control. But people lose trust in science when they receive, for example, dietary and nutritional advice that seems to contradict prior advice. Religion has often placed itself in opposition to science on matters ranging from evolution to plate tectonics.

It’s not an easy read, but if you have a nodding acquaintance with Karl Popper, T.S. Kuhn and W.V.O. Quine – all of whom get mentioned – you’ll find it worthwhile.

Spillover: Animal Infections and the Next Human Pandemic by David Quammen. (W.W. Norton, 2012).

Most new viruses enter the human population from animal reservoirs, the term for which is “zoonosis.” Strictly speaking, “zoonosis” is a noun that describes the pathogen (“SARS-CoV-2 is a zoonosis”) but informal usage in the press often misapplies the term to the process of interspecies infection. The scientific pronunciation is “ZOE-en-uh-sis” and this is nearly universal outside the US, but common variants in the US are “ZOO-en-uh-sis” and “zoo-EN-uh-sis.” The adjectival form is “zoonotic” (“SARS-CoV-2 is zoonotic”). In Greek, “zoo” means “animal” and “nosos” means “disease.” The opposite term is “anthroponosis,” a pathogen that is passed from humans to animals.

This book uses the more accessible and less scientific term “spillover” instead of “zoonosis,” and details specific examples that have been well documented, making the case that it is an extremely common occurrence that has happened with a huge variety of animals. Quammen writes: “I have asked [experts]… the same two-part question: (1) Will a new disease emerge, in the near future, sufficiently virulent and transmissible to cause a pandemic on the scale of AIDS or the 1918 flu, killing tens of millions of people? and (2) If so, what does it look like and whence does it come? Their answers to the first part have ranged from Maybe to Probably. Their answers to the second have focused on RNA viruses, especially those for which the reservoir host is some kind of primate. None of them has disputed the premise, by the way, that if there is a Next Big One it will be zoonotic.”

Anyone who advances the conspiracy theory that the SARS-CoV-2 virus that causes COVID-19 must have escaped from a laboratory in Wuhan, China, is ignorant of the basic fact that virus “spillover” is the norm, observed many, many times. Some on social media have suggested that the “coincidental” emergence of SARS-CoV-2 in the same city as the Wuhan Institute of Virology, China’s pre-eminent laboratory for the study of zoonoses, is “cirumstantial evidence” that the virus escaped from the lab, but the reason the lab was situated in Wuhan is because that is the heart of the region where zoonoses are most easily found, and the lab there has identified more than 300 different viruses in bats alone.

Such early warning researchers are critical, Quammen writes: “When the next novel virus makes its way from a chimpanzee, a bat, a mouse, a duck or a macaque into a human, and maybe from that human into another human, and thereupon begins causing a small cluster of lethal illnesses, they will see it – we hope they will, anyway – and raise the alarm. Whatever happens after that will depend on science, politics, social mores, public opinion, public will and other forms of human behavior. It will depend on how we citizens respond.”

Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It by Gina Kolata. (Farrar, Straus and Giroux, 1999).

The 1918 pandemic itself is not so much the subject of this book as a touchstone repeatedly used as a reference point to describe later attempts to recover old samples of it and genetically sequence it with modern tools, as well as more recent concerns such as a bird flu virus that made a leap as a zoonosis to humans in Hong Kong, setting off worries about a pandemic.

Numerous scientists (and a few non-scientists) want to understand the uniqueness of the 1918 pandemic. Why was it so deadly? Why did it kill victims mainly between ages 20 and 40, sparing those younger and those older? Was the 1918 influenza circulating years earlier without being noticed? Could an earlier 1890 strain have played a role, leaving antibodies in those who survived it? Raising more questions than answers, the book summarizes the state (or lack) of knowledge 20 years ago which, ironically, is not much different now.

One of the consistent themes is that many of the researchers are inspired by reading Crosby.

Pandemics: A Very Short Introduction by Christian W. McMillen. (Oxford University Press, 2016).

Taking the approach of historical survey, this book redefines pandemics in a somewhat unconventional way, devoting a chapter each to plague, smallpox, malaria, cholera, tuberculosis, influenza and HIV/AIDS. While the usual definition of pandemics is limited to diseases that briefly surge to kill perhaps a few million and then recede from the scene, including consistent threats such as malaria and tuberculosis changes the perspective. Even influenza, where particularly virulent strains can be orders of magnitude more deadly (as in 1918), is typically seen on an annual cycle with a death toll of 10,000 in the US in a “good” year.

Presidents, Pandemics, and Politics by Max J. Skidmore. (Palgrave Macmillan, 2016).

As Donald Trump has come under withering criticism for a slow and feckless response to the COVID-19 pandemic, including bizarre musings about injecting disinfectant into the human body, this book provides historical perspective, studying how Gerald Ford mishandled the 1976 swine flu scare, historically regarded as a gross overreaction, and examining the way predecessors such as Woodrow Wilson and Dwight Eisenhower addressed similar crises.

The core thesis: “Above all, the book demonstrates that efforts to impose severe limits on the size, scope and expense of government are dangerous. Government, and that means presidential action, often provides the best, and sometimes the only, method of protecting the population.”

Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways by Thomas J. Bollyky. (MIT Press, 2018).

Life expectancy has been increasing in the US with remarkable consistency since 1890, an overall trend as many childhood and other diseases have been almost eradicated, especially “plagues, parasites and viruses.” This book argues that disease has tracked humans from prehistoric times to the present, covering everything from sanitation to HIV/AIDS. While this is hardly a new or original argument, the book stands out for the level of detail, complete with charts and graphs, diving into the data. It is also notable for correcting factual errors often repeated uncritically elsewhere.

When Germs Travel: Six Major Epidemics That Have Invaded America Since 1900 and the Fears They Have Unleashed by Howard Markel. (Pantheon, 2004).

Infectious disease has often provoked paranoid xenophobia, just as Asian Americans today face prejudice for what Donald Trump has persisted in calling the “Chinese virus.” This book looks at anti-immigrant backlash ranging from tuberculosis, typhus and cholera to HIV/AIDS.