Dr. Philip Alcabes was kind enough to send me a review copy of his new book Dread: How Fear and Fantasy have Fueled Epidemics from the Black Death to the Avian Flu. I plan to review it for The Tyee, where I'm an editor, but we're now all wrapped up in the BC May 12 provincial election and won't have space for reviews until late this spring.
So here's a "pre-review," just to alert you to a very good and thought-provoking book.
In the early days of this blog, as I tried to make sense of news reports from the other side of the world, I often reflected that our response to a pandemic is limited by the terms of our culture. Those terms are so ingrained that we almost never think about them; we just take them as "common sense."
To outsiders, of course, our common sense may look like blind folly.
Dread is a history of cultural responses to pandemics and epidemics, especially since the Black Death of the mid-14th century. And since then the response of western cultures has essentially been to blame someone for upsetting the present social order.
In the 14th century, epidemics were seen to be divine punishment for bad behaviour, usually by unpopular groups. The urban poor, who caught plague more readily than the rich, clearly deserved it. So did the Jews, who were often slaughtered in huge pogroms before they ever got a chance to catch bubonic plague.
In later epidemics, like cholera, the presumed source of disease was an airborne "miasma" that infected the susceptible. The poor were again blamed for their illness. Now the cause of their misery was their tendency to live in filth and ignorance, combined with the feeble constitutions they gained from drink and dissipation.
Something similar was, to Europeans, the reason for the catastrophic destruction of the native peoples of the Americans, whose inferiority was clearly demonstrated by their inability to handle European diseases.
Alcabes makes a very interesting point: Since at least the 14th century, disease outbreaks have stimulated the growth of the modern state. If the ungodly were provoking divinely sent plagues, then the state and church needed to persecute the impious and sinful. If the bad habits of the poor were making them sick, then the state must control their licentious behaviour. Fear of epidemics, like fear of terrorism, gave the state enormous leverage against its own people.
So by the mid-19th century, when the germ theory of disease began to take hold, governments felt a duty to extend their powers still further, enforcing new levels of sanitation on the poor.
Surprisingly, Alcabes argues that the germ theory actually succeeded too well. The social conditions under which disease flourished were increasingly ignored. (Rudolf Virchow, the doctor who saw politics as the practice of medicine on a large scale, was a germ-theory skeptic.) Public health relied increasingly on promoting sanitation, and again blamed the poor for being dirty and ignorant.
In the squalid decades of immigration to North America, virtually every immigrant group was blamed for carrying some alarming new germ. After the cholera-carrying Irish of the 1840s and 50s, it was the Jews bringing TB and the Italians bringing polio. Blacks, of course, were famous carriers of syphilis.
Again, these imaginary susceptibilities to disease helped to stoke North American racism even as medical science began to understand how bacteria and viruses operate. The American eugenics movement, designed to prevent the inferior from reproducing, was the direct, Hitler-acknowledged inspiration for similar Nazi legislation against homosexuals, the mentally ill, and racial minorities.
One of Alcabes's most important points, if I understand him, is that these social responses were most intense in the cases of epidemics. The routine background noise of endemic disease has never stirred the same kind of anxiety.
And that helps me understand why we have few or no blogs dedicated to malaria, dengue, or tuberculosis. The infectious diseases that really kill us, like the auto accidents that also kill us by scores of thousands every year, just don't register.
Likewise with gunshot deaths, which in the US in 2005 totalled 30,694. (The toll since 1962 has been well over one million Americans.) Except for the occasional "shooting spree," such deaths draw little attention and no effort to prevent further mortality.
Instead, we worry about bad behaviour that leads to HIV/AIDS, or people with TB who neglect to take all their medicine and thereby help the bacterium gain resistance to antibiotics. Now, says Alcabes, the fear has shifted from the diseases themselves to conditions that increase "risk" of contracting them: obesity, unsafe sex, and so on.
And of course we worry (Alcabes thinks needlessly) about H5N1. Statistically, he has a good argument. Only one of the last four or five influenza pandemics was really deadly, and H5N1 could turn out to be just another Hong Kong flu, whose 500,000 deaths worldwide got very little press.
And as with early plagues, we tend to look for someone to blame for the spread of H5N1: Dr. Supari, and the ignorant villagers of her country; Chinese Communist officials who may be covering up outbreaks as they tried to do with SARS; ignorant West Bengali farmers; ignorant Vietnamese farmers; ignorant Egyptian housewives.
In these cases, as with early plagues, we may feel that our superior knowledge of the threat removes the issue of choice: If we're going to survive, we need to plan, to prepare, to alert our neighbours...and if necessary, impose emergency rules on the ignorant. And every new case, every new fatality, gives us a stronger argument for imposing those rules and punishing those (like Dr. Supari) who break them.
On these points Dr. Alcabes provides a useful perspective. Yes, it's a scandal that we don't attack the endemic diseases with the energy we devote to "virtual" pandemics. Yes, it's folly to ignore preventable deaths from accidents and violence. Yes, our worry about "risk" conditions at home permits us to ignore real diseases elsewhere.
And he is certainly right that we have ignored the social context that gives bacteria and viruses their big opportunity. While he might not say it as bluntly, much of what we consider hygiene is little more than an attempt by the anxious middle class to control the dirty, lawless, sexually profligate poor.
Nonetheless, the attention we give to H5N1—and to HIV/AIDS, and to Ebola, and to the other "emerging diseases"—should teach us something about the endemic diseases as well.
We are learning, whether we want to or not, about the social and cultural conditions in the hot-zone countries that promote the spread of bird flu. We are learning about our own political priorities, and how they amount to the practice (and malpractice) of large-scale medicine in our own countries. And what we learn about H5N1 in particular should teach us a lot about viruses in general.
If we plan for pandemic, we also plan for earthquakes, ice storms, and hurricanes, and thereby do ourselves and our communities some good. If we realize that our poorer neighbours can't afford to do such planning, or even to get routine health care, we may start pushing for a more robust and inclusive health-care system.
So I strongly recommend that you read Dread. You don't have to agree with everything that Alcabes says, but it will probably do you good to look at H5N1 from his perspective.
