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Why Pandemics Are Our Own Damn Fault

A review of Sonia Shah's brilliant new book on 21st century disease threats we all face.

Crawford Kilian 2 Apr

Tyee contributing editor Crawford Kilian follows the politics of public health on his blog H5N1.

An American science journalist, Sonia Shah has published earlier books on malaria and the testing of pharmaceuticals in poor countries. She must have understood the challenge of her new book, Pandemic: Tracking Contagions, From Cholera to Ebola and Beyond, and what it would take to organize a vast body of research -- not only that, but to make that research understandable to a lay audience.

She has succeeded brilliantly. On page one, she describes her flight from Haiti to Florida, delayed because another passenger had come down with cholera just as he took his seat on the plane. By page two, I knew I was in good hands and I was not disappointed by the time I reached the extensive documentation. This is the best single book I have yet read about the disease threats we all face in the 21st century.

I say this as a blogger who since 2005 has posted over 45,000 times about disease outbreaks and the political and scientific responses to them. If nothing else, the experience has taught me that organizing information about diseases is a very tough job. That may be why so many outbreaks seem to come out of nowhere -- we have no idea of their backstory.

Shah builds her book around the backstory of a single disease: cholera. But in explaining it, she takes us on a superbly guided tour of many other diseases. Each may have its own symptoms but all, she argues, rely on humans to spread them.

Vibrio cholera was an unassuming marine bacterium, minding its own business in warm coastal waters, until the British East India Company occupied and developed the coast of what is now Bangladesh in the late 18th century. By turning the wetlands into farmlands, the British disturbed the local ecosystem and brought humans into much closer contact with Vibrio cholera.

Once cholera got into human beings, it quickly learned how to destroy other bacteria in the human gut by producing a toxin that would flush everything else out. Typically humans would dehydrate and die in hours, but their excrement would spread cholera to their caregivers and the local water supply.

Steamboats as cholera vectors

India's first cholera outbreak was in 1817. Newfangled steamboats carried it to Europe within a few years, and then to the Americas. Humanity was what epidemiologists now call a ''naive'' population, utterly lacking in immunity to this new threat, and we died in millions.

Shah argues that we kept on dying of cholera because our concept of disease, our ''paradigm,'' was still that of the ancient Greeks. They saw disease as an imbalance between the individual and his or her environment, and for over a thousand years their view was accepted and taught. By the 19th century, this had evolved into the ''miasma'' theory that disease was the result of breathing bad air. (''Malaria'' means just that.) If something smelled bad, the smell alone could make you sick.

Bacteria had been observed in microscopes since the 17th century, but the miasmatic paradigm had no room for them. When people started dying of cholera in London, the response was to pump more sewage into the Thames. People downstream might drink it, but they wouldn't smell it.

Dr. John Snow famously located the source of one London cholera outbreak in a single neighbourhood water pump, but his medical colleagues dismissed him as a crank; he was thinking outside the paradigm. He died of a stroke at 45, and cholera continued to spread. Only after Louis Pasteur did the germ theory become the new medical paradigm.

Nevertheless, we are now a quarter-century into the seventh cholera pandemic, which began in South America in the 1990s and climaxed in the imported catastrophe of cholera in Haiti, which has killed 10,000 people since 2010. We've learned a lot but not enough.

Similarly, other diseases have emerged as we pushed the interface between wilderness and ourselves, and as our very success crowded more of us together. HIV/AIDS emerged from the exploitation of central Africa's forests and spread worldwide by air travel. Many of South China's millions make their living off pigs, poultry, and occasional wild animals; those in turn have given us countless strains of bird flu as well as SARS. And deforestation in West Africa seems to have disturbed the bat populations, which carried the Ebola virus into human settlements.

Prosperity can be hazardous to your health

Shah explains all this very clearly, even the technical material, and finds that modern outbreaks have much in common. Ironically, prosperity is often the culprit: As China opened up to international trade, millions with money in their pockets began to demand more meat -- pork, fowl, and wild animals. Chinese farms produced more livestock to meet the demand, and wild animals were hunted for the menus of ''wild taste'' restaurants.

The result was the eruption of new bird flus, starting with H5N1 in Hong Kong in 1997. Then SARS emerged from ''wild taste'' restaurants. In Malaysia, Nipah virus moved from bats to pigs. Routine smuggling of livestock across Asian borders was driven by demand from still more consumers.

Modern technology has only made prosperity still more hazardous. Just as steamships carried cholera from Europe to the Americas, affordable air travel has spread these new diseases. SARS hopped from a Hong Kong hotel to Vancouver and Toronto in a matter of hours. British schoolgirls on holiday in Mexico in 2009 brought H1N1 pandemic flu home as a souvenir. A young Alberta nurse, returning from a holiday in Beijing in Dec. 2013, died of H5N1 in her own Red Deer hospital a few days later.

Medical tourism compounds the problem: Many people travel to countries like India for cut-rate surgery and come home with more problems. Since 2008, Shah points out, such tourists in New Delhi have been picking up NDM-1, a fragment of DNA that can move between bacteria and endow them with superpowers of resistance to antibiotics. Western hospitals are already struggling to suppress bugs like ''methicillin-resistant Staphylococcus aureus'' (MRSA) and E. coli. If NDM-1 really spreads, we will find ourselves back in the pre-antibiotic 19th century.

Shah and her family already know what that means: She describes how she and her sons have been fighting MRSA since 2010, swapping it back and forth despite endless regimes of antibiotics. I can sympathize; my mother died of MRSA in a nursing home at the age of 95.

Cooperation in the spread

The 19th-century German doctor and politician Rudolf Virchow said: ''Medicine is a social science, and politics is nothing else but medicine on a large scale.'' Too often, politics is medical malpractice on a gigantic scale.

Shah notes the cooperation of governments in spreading diseases. Italy suppressed news of a cholera outbreak in 1911, just before the 50th anniversary celebrations of the country's unification. Spanish influenza got its name because only Spain, a neutral country, reported cases of the new flu. The combatants censored all reports; the Americans rushed more troops to Europe in crowded conditions that ensured still more cases.

More recent governments have done the same thing: Indonesia refused to report human H5N1 cases for a long time, China was silent on SARS for months (and is now reticent about H7N9 bird flu), and Saudi Arabia has released almost no data on Middle East respiratory syndrome, which tends to spread in Saudi hospitals. Even the World Health Organization was reluctant to mention Ebola at first, fearing the economic impact on West Africa's economies.

Without belabouring the point, Shah makes it clear that pandemics are largely our own damn fault. We clear-cut forests, use our rivers as sewers, insist on flying cheaply wherever we please, underfund our healthcare systems, and misuse medical advances such as antibiotics. We even have to be reminded to wash our hands.

Worse yet, we seem unable to think outside our own culture. West Africans encouraged the spread of Ebola by the custom of bathing and kissing their dead before burial. That showed love and respect. Our own culture expects sanitation as a matter of course, but then tolerates undrinkable water in Canada's First Nations and actually imposes lead poisoning on the people of Flint, Michigan, as a cost-saving measure. That shows love and respect for the taxpayer.

Sonia Shah's Pandemic shows that it is indeed possible to step out of our culture and see how it may be our own worst enemy. If we ignore her warning, we'll have only ourselves to blame for the consequences.  [Tyee]

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