It seems there’s nothing like a pandemic to get people reading—and writing—medical history. Even before the emergence of SARS-CoV-2, historians and a few historically minded anthropologists were looking into the meaning and significance of epidemics. They studied particularly the rise, during the past 40 years, of ecological explanations of disease patterns, theories of “emergency” and “crisis,” and practices of biosecurity, surveillance, and preparedness. Through transforming knowledge of our relations with the microbial world, these historians and anthropologists are helping to equip us for our current predicament—equipping us, as it were, not with physical personal protective equipment (PPE) like masks, but with equally effective cognitive PPE.
In 2020, as COVID-19 spread insidiously around the world, the major outcomes of this long-term research conveniently materialized in a flurry of books: most notably, in Mark Honigsbaum’s The Pandemic Century, Lyle Fearnley’s Virulent Zones, and Andrew Lakoff’s Unprepared. These books appear just when we need them, at the right time to help us to understand and withstand the pandemic. So, what can we learn from this new cognitive PPE?
Mulling over these three books after the advent of COVID-19 leaves me with a worrisome impression. In recent decades, significant energy and funding have been devoted to preparing for a future epidemic—to managing the unknown. Yet these studies make clear that much of that effort and money might have been better expended in research on disease ecology and the social determinants of health—on making the unknown known.
Certainly, preparedness planning appears to have done little or nothing actually to prepare us for the current pandemic. A decade of technocratic exercises designed to achieve global-health security now looks like a colossal, and tragic, waste of time and resources. Rather than simply accepting that a virus will come, instead, we might follow a new path: learning how these viruses live and thrive—and working to suppress or deflect them before they take off.
Diseases are only calamities from the human’s point of view; from the microbe’s perspective, pandemics must look more like flourishing.
Making the unknown known begins with abandoning deficient and inadequate ways of understanding viruses. For a start, infectious-disease prevention and control are never simply about “microbe hunting.” Ever since so many diseases were attributed to particular germs late in the 19th century, the sport of chasing the causative organism has become a common theme in the development of epidemiology, the statistical study of disease outbreaks.
As a medical student in the 1970s, I was inspired by Paul de Kruif’s tales of gallant disease detectives, published originally in 1926 and long a staple in the education of budding health professionals.1 It seemed pretty straightforward: all you had to do was track down and isolate the germ, using the tools of a microbiology laboratory, then do a bit of contact tracing and isolation or quarantine of spreaders and carriers—and that would both explain and contain the epidemic. If only it were that easy.
Working out disease patterns, as de Kruif occasionally hinted, often proved far more complicated and scrambled in practice. The emergence and worldwide spread of influenza in 1918, for example, provoked consternation and bewilderment among epidemiologists, who struggled to explain how it happened and what it meant. In the interwar years, many infectious-disease specialists turned to broader evolutionary principles to make sense of interactions of microbes or parasites with their hosts—that is, with us. These biomedical experts aimed to integrate the new microbiology with an older macrobiology, hoping thereby to comprehend how equilibria between germs and their hosts might become disturbed, causing diseases to emerge.
One of the leading figures in this effort to make the mapping of disease patterns more complex and realistic was F. Macfarlane Burnet, a taciturn Australian virologist with uncanny biological intuition, who coined the term “disease ecology” in the late 1930s. Burnet described vividly the struggle for existence between humans and their parasites, an eternal tussle in which the microbes for a time might gain the upper hand, causing what we know as an epidemic.
Ever sensitive to pathologies of progress, Burnet warned that wars, migrations, advances in mobility, human overcrowding, financial depression, and environmental degradation were likely to aid and abet such disease emergence. So-called civilization, he lamented, was letting loose new calamities.2 Yet these were only calamities from the human’s point of view; from the microbe’s perspective, after all, pandemics must look more like flourishing.
Burnet’s jeremiads from down under attracted little attention from other epidemiologists during a period when infectious disease seemed to be declining, at least in wealthy countries. With the advent of AIDS in the 1980s, however, this blithe disregard turned occasionally to intense scrutiny. Suddenly, at least some epidemiologists came to see the utility of Burnet’s “ecological” thought in figuring out why new diseases, such as AIDS (and later, influenza variants, Ebola, SARS, MERS, Zika, and so on), might emerge as if out of nowhere and afflict us. Soon, new ecologically informed research enterprises, such as One Health, EcoHealth, and now the planetary-health movement, were proliferating in global public health.3 Even so, the rising ecological clamor remained virtually inaudible to most policy makers and to the public.
When we seek to understand patterns of infectious disease, we have a choice to make. One option is to default to facile assumptions of contamination, the sense that mere contact or proximity leads inevitably to danger and defilement. Of course, it’s true that contagion is not an uncommon means of spreading germs, but person-to-person contact is never without context, whether ecological or social. While it may be possible to perform adequate microbe hunting using a simplistic contamination model, such reductive accounts won’t help us to understand why a particular disease appeared in the first place. Contamination thinking can’t show how an epidemic emerged, where it’s going, and what we should do to arrest it.
The other option, as historian Charles E. Rosenberg noted in relation to AIDS, is to try to grasp the configuration of an epidemic.4 Understanding the configuration of a disease is necessary if we want to learn about its origin, structure, and future course. We need to be able to situate disease and contextualize it.
Since the 1980s, then, ecology has offered a powerful method of engaging with the biological configurations and complexities of emerging diseases. Ecology—as a mode of configuring—is a more intricate means of collecting epidemic intelligence; so much so that ecological explanations have tended to displace older sociological insight into economic and political factors, which also influence the distribution and abundance of germs, and, hence, patterns of infectious disease.
For some, social medicine, as propounded first by German pathologist Rudolf Virchow from the 1840s, continues to furnish an alternative integrative framework for making sense of disease emergence. Like ecology, social medicine suggests a source for complexity in epidemiology, but one affording a contrasting socioeconomic configuration.5 Still, social medicine seems to be struggling to gain attention these days.
Both ecology and sociology provide distinctive and, so far, divergent modes of rendering our understanding of epidemics more elaborate and multifaceted. And, in so doing, both potentially make our framing of disease and our epidemic intelligence more constructive and serviceable. Yet disease ecologists and aficionados of social medicine seem more often to be in competition than accord, usually talking over one another.
This is where history becomes useful in unraveling our current assumptions and misapprehensions. At first, the appearance of COVID-19 in Wuhan, China, incited various ecological speculations about why the epidemic might emerge there at that particular time. Admittedly, those arguing for interspecies transmission (often including bat and pangolin consumption) invoked stigmatizing accusations of “primitive” customs and habits more often than they considered modern ecological hazards, such as urbanization, industrial agriculture, and efficient transport networks. But it was a start.
Since then, occasional flickers of social medicine have shown up in observations of the influence of racial and socioeconomic disparities on disease prevalence. Before long, however, much more simplistic contamination models, shorn of any ecological and sociological complexity, came to dominate most accounts of the worldwide spread of the novel coronavirus. Contact implied danger, defilement brought disease. Therefore, it has fallen to historians and anthropologists to show us how we might yet have structural complexity, or at least a sense of configuration, in our apprehensions of the pandemic.
In The Pandemic Century, a masterful tour of the receding horizon of past plagues, Mark Honigsbaum repeatedly scrutinizes the obsession of modern medicine and public health with developing new diagnostics and technical preventive measures—such as vaccines—in order to contain disease outbreaks. Often, this narrow a focus on technological “solutions” has led to the neglect of the complex ecological and immunological reasons behind the emergence and spread of such human afflictions.
With marked brio and impressive detail, Honigsbaum surveys the histories of outbreaks of influenza in 1918–19, bubonic plague in Los Angeles in 1924, psittacosis (an ailment of parrots that can cross over to humans) in 1929–30, Legionnaires’ disease in Philadelphia in 1976, AIDS since 1981, SARS in East Asia in 2003, Ebola in West Africa in 2014, and Zika in the Americas in 2015. The lesson of history is clear, according to Honigsbaum: we desperately need “a more nuanced view of our complex interactions with microbes.” Each of the examples he highlights indicates “the dangers of overreliance on particular technologies at the expense of wider ecological insights into disease causation.” The story of SARS, another coronavirus, is especially pertinent, as it links the crowding together of horseshoe bats, palm civets, and humans to the evolution and transmission of the virus in the markets of Shenzhen—conjuring a sort of ecological déjà vu in the era of COVID-19.
Published only in 2019, the first edition of The Pandemic Century stopped at Zika. The revised 2020 version concludes, inevitably, with COVID-19, the much anticipated “Disease X.” Written in March and April 2020, Honigsbaum’s account of the new pandemic is already dated, so much so that it seems premature, even opportunistic. But he deftly draws out parallels with previous infectious calamities. Each epidemic, he writes, “is part of an ecological web that is itself influenced by a constellation of shifting economic, social, and environmental factors.”
Like Frank Snowden in his excellent Epidemics and Society: From the Black Death to the Present,6 Honigsbaum eloquently makes the case for better understanding the ecological configurations of disease outbreaks. All the same, we continue to discount or marginalize the ecology of disease emergence and transmission, while happily investing in reductionist technical interventions based on simplistic contamination models.
We may have a lot to learn from interspecies ecological research in Hong Kong and southern China concerning disease outbreaks.
In Virulent Zones, we can now follow anthropologist Lyle Fearnley into the farms and fields of southern China. These are the source of multiple influenza pandemics and coronavirus outbreaks, so we need to listen carefully to the conversations he has there with virologists, veterinarians, birders, and ordinary laborers. More an ecology sleuth than a microbe hunter, Fearnley wants to find out what disease ecology looks like at ground zero around Poyang Lake. He shows us “how China’s landscapes of intensive livestock farming and state biopolitics created ecologies of influenza that exceeded global-health models and assumptions.”
According to Fearnley, Hong Kong since the 1980s has also been especially fertile in generating ecological thought about the emergence of new viruses, in tracking cross-species transmissions, and in assaying the impact of changing farming practices, urban overcrowding, and population mobility on the distribution and abundance of germs in the region. The emergence of H5N1 influenza in 1997 stimulated further ecological inquiries, prompting virologists and epidemiologists to leave their city laboratories and offices to venture into the fields to work out how domesticated poultry, wild birds, pigs, and humans were interacting to cause viral epidemics. It turns out influenza viruses tend to incubate and mutate in wild geese and flocks of ducks and chickens before infecting proximate humans in cramped conditions.
Fearnley probably overstates the novelty of such fieldwork in disease ecology. But he does make a compelling argument for the move away from older microevolutionary theories of pathogenesis, based on competition of hosts and parasites, toward a more systemic and rigorous reckoning—a dynamic configuration—of how environments and animal populations (human and nonhuman) connect up to promote viral innovation.
Meanwhile, he points out that the WHO and other global-health organizations still focus conventionally on viral surveillance, vaccine development, and preparedness planning. This is another way of saying that such crucial organizations have mostly ignored developments in disease ecology. In other words, we may have a lot to learn from interspecies ecological research in Hong Kong and southern China concerning disease outbreaks. As Fearnley concludes, in relation to COVID-19: “If there is any hope in predicting and preventing the next emerging viral pathogen, it will rely on inventing new instruments of ecological and social research that are capable of tracing the links between viruses and their environments.” Perhaps, then, less talk of the “China virus” and more attention to the insights of Chinese disease ecology?
Both Honigsbaum and Fearnley show us there can be no reliable biosecurity or epidemic preparedness without insight from disease ecology and social medicine. Similarly, anthropologist Frédéric Keck, who traverses some of Fearnley’s territory in Avian Reservoirs: Virus Hunters and Birdwatchers in Chinese Sentinel Posts, calls for a “shift in the reflection on preparedness from the short temporality of emergencies to the long temporality of ecologies.”7
The dire ecological and sociological impoverishment of pre–COVID-19 imaginings of biosecurity and preparedness is vividly revealed in Andrew Lakoff’s Unprepared: Global Health in a Time of Emergency. Lakoff exhaustively documents global efforts to classify, regulate, and technically circumscribe outbreaks of novel diseases, describing how the global-health industry in the early 21st century has redefined and reclassified events like “crises” and “emergencies” and reframed “biosecurity” and “preparedness.”
Another anthropologist venturing into recent historical analysis, Lakoff adroitly shows how management theories, civil-defense practices, and risk analysis came to inform and limit responses to disease emergence. Focusing on the United States after the September 11, 2001, terrorist attacks and Hurricane Katrina in 2005, he explains how “national preparedness provides authorities with tools for grasping uncertain future events and bringing them into a space of present intervention.”
In effect, preparedness becomes our last resort when risk assessment fails. Often this involves the modeling or imaginative reenactment of potentially catastrophic events whose likelihood escapes calculation—such as the emergence of a novel coronavirus. Thus, Lakoff tracks the swarm of global bodies and their confusing acronyms (ProMED, GPHIN, GOARN, GISN, and so on), all dedicated to assessing the risk of disease emergence or, when that fails, managing the unknown by performing imaginative enactments of worst-case scenarios, often focused on rapid pharmaceutical and vaccine development. Disease ecology and social medicine, which might help make known the lurking unknown, have become utterly marginal to this furor of modeling and simulation.
We can read Honigsbaum’s and Fearnley’s books with profit to learn more about our current predicament, to see how historical perceptions and responses are repeated or modified as we come to terms with the pandemic that confronts us today. Reading Lakoff’s book performs a different function, exposing the remoteness or inapplicability of some recent global-health endeavors, illustrating what went wrong or what turned out to be futile. Sadly, such distressing historical failures, as much as any ecological glimmers of hope, condition the way we live now.
This article was commissioned by Caitlin Zaloom.
- Paul de Kruif, Microbe Hunters (1926; repr., Houghton Mifflin Harcourt, 2002). ↩
- See Warwick Anderson, “Natural Histories of Infectious Disease: Ecological Vision in Twentieth-Century Biomedical Science,” Osiris, vol. 19 (2004). ↩
- James Dunk and Warwick Anderson, “Assembling Planetary Health: Histories of the Future,” in Planetary Health: Protecting Nature to Protect Ourselves, edited by Samuel S. Myers and Howard Frumkin (Island Press, 2020). ↩
- Charles E. Rosenberg, “Explaining Epidemics,” in Explaining Epidemics, and Other Studies in the History of Medicine (Cambridge University Press, 1992). ↩
- For example, Paul Farmer, Infections and Inequalities: The Modern Plagues (University of California Press, 2001). ↩
- Frank M. Snowden, Epidemics and Society: From the Black Death to the Present (Yale University Press, 2019). ↩
- Frédéric Keck, Avian Reservoirs: Virus Hunters and Birdwatchers in Chinese Sentinel Posts (Duke University Press, 2020), p. 177. ↩