Pandemics: A Very Short Introduction VERY SHORT INTRODUCTIONS are for anyone wanting a stimulating and accessible way into a new subject. They are written by experts, and have been translated into more than 40 different languages. The series began in 1995, and now covers a wide variety of topics in every discipline. The VSI library now contains over 450 volumes—a Very Short Introduction to everything from Indian philosophy to psychology and American history and relativity—and continues to grow in every subject area.

Very Short Introductions available now:

ACCOUNTING Christopher Nobes ANAESTHESIA Aidan O’Donnell ADOLESCENCE Peter K. Smith ANARCHISM Colin Ward ADVERTISING Winston Fletcher ANCIENT ASSYRIA Karen Radner AFRICAN AMERICAN RELIGION ANCIENT EGYPT Ian Shaw Eddie S. Glaude Jr ANCIENT EGYPTIAN ART AND AFRICAN HISTORY John Parker and ARCHITECTURE Christina Riggs Richard Rathbone ANCIENT GREECE Paul Cartledge AFRICAN RELIGIONS Jacob K. Olupona THE ANCIENT NEAR EAST AGNOSTICISM Robin Le Poidevin Amanda H. Podany AGRICULTURE Paul Brassley and ANCIENT PHILOSOPHY Julia Annas Richard Soffe ANCIENT WARFARE ALEXANDER THE GREAT Harry Sidebottom Hugh Bowden ANGELS David Albert Jones ALGEBRA Peter M. Higgins ANGLICANISM Mark Chapman AMERICAN HISTORY Paul S. Boyer THE ANGLO-SAXON AGE AMERICAN IMMIGRATION John Blair David A. Gerber THE ANIMAL KINGDOM AMERICAN LEGAL HISTORY Peter Holland G. Edward White ANIMAL RIGHTS David DeGrazia AMERICAN POLITICAL HISTORY THE ANTARCTIC Klaus Dodds Donald Critchlow ANTISEMITISM Steven Beller AMERICAN POLITICAL PARTIES ANXIETY Daniel Freeman and AND ELECTIONS L. Sandy Maisel Jason Freeman AMERICAN POLITICS THE APOCRYPHAL GOSPELS Richard M. Valelly Paul Foster THE AMERICAN PRESIDENCY ARCHAEOLOGY Paul Bahn Charles O. Jones ARCHITECTURE Andrew Ballantyne THE AMERICAN REVOLUTION ARISTOCRACY William Doyle Robert J. Allison ARISTOTLE Jonathan Barnes AMERICAN SLAVERY ART HISTORY Dana Arnold Heather Andrea Williams ART THEORY Cynthia Freeland THE AMERICAN WEST Stephen Aron ASTROBIOLOGY David C. Catling AMERICAN WOMEN’S HISTORY ASTROPHYSICS James Binney Susan Ware ATHEISM Julian Baggini AUGUSTINE Henry Chadwick CHRISTIANITY Linda Woodhead AUSTRALIA Kenneth Morgan CITIZENSHIP Richard Bellamy AUTISM Uta Frith CIVIL ENGINEERING David Muir Wood THE AVANT GARDE David Cottington CLASSICAL LITERATURE THE AZTECS Davíd Carrasco William Allan BABYLONIA Trevor Bryce CLASSICAL MYTHOLOGY BACTERIA Sebastian G. B. Amyes Helen Morales BARTHES Jonathan Culler CLASSICS Mary Beard and THE BEATS David Sterritt John Henderson BEAUTY Roger Scruton CLAUSEWITZ Michael Howard BESTSELLERS John Sutherland CLIMATE Mark Maslin THE BIBLE John Riches CLIMATE CHANGE Mark Maslin BIBLICAL ARCHAEOLOGY COGNITIVE NEUROSCIENCE Eric H. Cline Richard Passingham BIOGRAPHY Hermione Lee THE COLD WAR Robert McMahon BLACK HOLES Katherine Blundell COLONIAL AMERICA Alan Taylor BLOOD Chris Cooper COLONIAL LATIN AMERICAN THE BLUES Elijah Wald LITERATURE Rolena Adorno THE BODY Chris Shilling COMBINATORICS Robin Wilson THE BOOK OF MORMON COMEDY Matthew Bevis Terryl Givens COMMUNISM Leslie Holmes BORDERS Alexander C. Diener and COMPLEXITY John H. Holland Joshua Hagen THE COMPUTER Darrel Ince THE BRAIN Michael O’Shea COMPUTER SCIENCE THE BRICS Andrew F. Cooper Subrata Dasgupta THE BRITISH CONSTITUTION CONFUCIANISM Daniel K. Gardner Martin Loughlin THE CONQUISTADORS THE BRITISH EMPIRE Ashley Jackson Matthew Restall and BRITISH POLITICS Anthony Wright Felipe Fernández-Armesto BUDDHA Michael Carrithers CONSCIENCE Paul Strohm BUDDHISM Damien Keown CONSCIOUSNESS Susan Blackmore BUDDHIST ETHICS Damien Keown CONTEMPORARY ART BYZANTIUM Peter Sarris Julian Stallabrass CANCER Nicholas James CONTEMPORARY FICTION CAPITALISM James Fulcher Robert Eaglestone CATHOLICISM Gerald O’Collins CONTINENTAL PHILOSOPHY CAUSATION Stephen Mumford and Simon Critchley Rani Lill Anjum COPERNICUS Owen Gingerich THE CELL Terence Allen and CORAL REEFS Charles Sheppard Graham Cowling CORPORATE SOCIAL THE CELTS Barry Cunliffe RESPONSIBILITY Jeremy Moon CHAOS Leonard Smith CORRUPTION Leslie Holmes CHEMISTRY Peter Atkins COSMOLOGY Peter Coles CHILD PSYCHOLOGY Usha Goswami CRIME FICTION Richard Bradford CHILDREN’S LITERATURE CRIMINAL JUSTICE Julian V. Roberts Kimberley Reynolds CRITICAL THEORY Stephen Eric Bronner CHINESE LITERATURE Sabina Knight THE CRUSADES Christopher Tyerman CHOICE THEORY Michael Allingham CRYPTOGRAPHY Fred Piper and CHRISTIAN ART Beth Williamson Sean Murphy CHRISTIAN ETHICS D. Stephen Long CRYSTALLOGRAPHY A. M. Glazer THE CULTURAL REVOLUTION EPIDEMIOLOGY Rodolfo Saracci Richard Curt Kraus ETHICS Simon Blackburn DADA AND SURREALISM ETHNOMUSICOLOGY Timothy Rice David Hopkins THE ETRUSCANS Christopher Smith DANTE Peter Hainsworth and THE EUROPEAN UNION John Pinder David Robey and Simon Usherwood DARWIN Jonathan Howard EVOLUTION Brian and THE DEAD SEA SCROLLS Deborah Charlesworth Timothy Lim EXISTENTIALISM Thomas Flynn DECOLONIZATION Dane Kennedy EXPLORATION Stewart A. Weaver DEMOCRACY Bernard Crick THE EYE Michael Land DERRIDA Simon Glendinning FAMILY LAW Jonathan Herring DESCARTES Tom Sorell FASCISM Kevin Passmore DESERTS Nick Middleton FASHION Rebecca Arnold DESIGN John Heskett FEMINISM Margaret Walters DEVELOPMENTAL BIOLOGY FILM Michael Wood Lewis Wolpert FILM MUSIC Kathryn Kalinak THE DEVIL Darren Oldridge THE FIRST WORLD WAR DIASPORA Kevin Kenny Michael Howard DICTIONARIES Lynda Mugglestone FOLK MUSIC Mark Slobin DINOSAURS David Norman FOOD John Krebs DIPLOMACY Joseph M. Siracusa FORENSIC PSYCHOLOGY DOCUMENTARY FILM David Canter Patricia Aufderheide FORENSIC SCIENCE Jim Fraser DREAMING J. Allan Hobson FORESTS Jaboury Ghazoul DRUGS Les Iversen FOSSILS Keith Thomson DRUIDS Barry Cunliffe FOUCAULT Gary Gutting EARLY MUSIC Thomas Forrest Kelly THE FOUNDING FATHERS THE EARTH Martin Redfern R. B. Bernstein EARTH SYSTEM SCIENCE Tim Lenton FRACTALS Kenneth Falconer ECONOMICS Partha Dasgupta FREE SPEECH Nigel Warburton EDUCATION Gary Thomas FREE WILL Thomas Pink EGYPTIAN MYTH Geraldine Pinch FRENCH LITERATURE EIGHTEENTH-CENTURY BRITAIN John D. Lyons Paul Langford THE FRENCH REVOLUTION THE ELEMENTS Philip Ball William Doyle EMOTION Dylan Evans FREUD Anthony Storr EMPIRE Stephen Howe FUNDAMENTALISM Malise Ruthven ENGELS Terrell Carver FUNGI Nicholas P. Money ENGINEERING David Blockley GALAXIES John Gribbin ENGLISH LITERATURE Jonathan Bate GALILEO Stillman Drake THE ENLIGHTENMENT GAME THEORY Ken Binmore John Robertson GANDHI Bhikhu Parekh ENTREPRENEURSHIP Paul Westhead GENES Jonathan Slack and Mike Wright GENIUS Andrew Robinson ENVIRONMENTAL ECONOMICS GEOGRAPHY John Matthews and Stephen Smith David Herbert ENVIRONMENTAL POLITICS GEOPOLITICS Klaus Dodds Andrew Dobson GERMAN LITERATURE EPICUREANISM Catherine Wilson Nicholas Boyle GERMAN PHILOSOPHY Andrew Bowie INFECTIOUS DISEASE Marta L. Wayne GLOBAL CATASTROPHES Bill McGuire and Benjamin M. Bolker GLOBAL ECONOMIC HISTORY INFORMATION Luciano Floridi Robert C. Allen INNOVATION Mark Dodgson and GLOBALIZATION Manfred Steger David Gann GOD John Bowker INTELLIGENCE Ian J. Deary GOETHE Ritchie Robertson INTERNATIONAL LAW Vaughan Lowe THE GOTHIC Nick Groom INTERNATIONAL MIGRATION GOVERNANCE Mark Bevir Khalid Koser THE GREAT DEPRESSION AND THE INTERNATIONAL RELATIONS NEW DEAL Eric Rauchway Paul Wilkinson HABERMAS James Gordon Finlayson INTERNATIONAL SECURITY HAPPINESS Daniel M. Haybron Christopher S. Browning THE HARLEM RENAISSANCE IRAN Ali M. Ansari Cheryl A. Wall ISLAM Malise Ruthven THE HEBREW BIBLE AS LITERATURE ISLAMIC HISTORY Adam Silverstein Tod Linafelt ISOTOPES Rob Ellam HEGEL Peter Singer ITALIAN LITERATURE HEIDEGGER Michael Inwood Peter Hainsworth and David Robey HERMENEUTICS Jens Zimmermann JESUS Richard Bauckham HERODOTUS Jennifer T. Roberts JOURNALISM Ian Hargreaves HIEROGLYPHS Penelope Wilson JUDAISM Norman Solomon HINDUISM Kim Knott JUNG Anthony Stevens HISTORY John H. Arnold KABBALAH Joseph Dan THE HISTORY OF ASTRONOMY KAFKA Ritchie Robertson Michael Hoskin KANT Roger Scruton THE HISTORY OF CHEMISTRY KEYNES Robert Skidelsky William H. Brock KIERKEGAARD Patrick Gardiner THE HISTORY OF LIFE Michael Benton KNOWLEDGE Jennifer Nagel THE HISTORY OF MATHEMATICS THE KORAN Michael Cook Jacqueline Stedall LANDSCAPE ARCHITECTURE THE HISTORY OF MEDICINE Ian H. Thompson William Bynum LANDSCAPES AND THE HISTORY OF TIME GEOMORPHOLOGY Leofranc Holford‑Strevens Andrew Goudie and Heather Viles HIV/AIDS Alan Whiteside LANGUAGES Stephen R. Anderson HOBBES Richard Tuck LATE ANTIQUITY Gillian Clark HOLLYWOOD Peter Decherney LAW Raymond Wacks HORMONES Martin Luck THE LAWS OF THERMODYNAMICS HUMAN ANATOMY Peter Atkins Leslie Klenerman LEADERSHIP Keith Grint HUMAN EVOLUTION Bernard Wood LEARNING Mark Haselgrove HUMAN RIGHTS Andrew Clapham LEIBNIZ Maria Rosa Antognazza HUMANISM Stephen Law LIBERALISM Michael Freeden HUME A. J. Ayer LIGHT Ian Walmsley HUMOUR Noël Carroll LINCOLN Allen C. Guelzo THE ICE AGE Jamie Woodward LINGUISTICS Peter Matthews IDEOLOGY Michael Freeden LITERARY THEORY Jonathan Culler INDIAN CINEMA Ashish Rajadhyaksha LOCKE John Dunn INDIAN PHILOSOPHY Sue Hamilton LOGIC Graham Priest LOVE Ronald de Sousa MOLECULAR BIOLOGY Aysha Divan MACHIAVELLI Quentin Skinner and Janice A. Royds MADNESS Andrew Scull MOLECULES Philip Ball MAGIC Owen Davies THE MONGOLS Morris Rossabi MAGNA CARTA Nicholas Vincent MOONS David A. Rothery MAGNETISM Stephen Blundell MORMONISM Richard Lyman Bushman MALTHUS Donald Winch MOUNTAINS Martin F. Price MANAGEMENT John Hendry MUHAMMAD Jonathan A. C. Brown MAO Delia Davin MULTICULTURALISM Ali Rattansi MARINE BIOLOGY Philip V. Mladenov MUSIC Nicholas Cook THE MARQUIS DE SADE John Phillips MYTH Robert A. Segal MARTIN LUTHER Scott H. Hendrix THE NAPOLEONIC WARS MARTYRDOM Jolyon Mitchell Mike Rapport MARX Peter Singer NATIONALISM Steven Grosby MATERIALS Christopher Hall NELSON MANDELA Elleke Boehmer MATHEMATICS Timothy Gowers NEOLIBERALISM Manfred Steger and THE MEANING OF LIFE Terry Eagleton Ravi Roy MEDICAL ETHICS Tony Hope NETWORKS Guido Caldarelli and MEDICAL LAW Charles Foster Michele Catanzaro MEDIEVAL BRITAIN John Gillingham THE NEW TESTAMENT and Ralph A. Griffiths Luke Timothy Johnson MEDIEVAL LITERATURE THE NEW TESTAMENT AS Elaine Treharne LITERATURE Kyle Keefer MEDIEVAL PHILOSOPHY NEWTON Robert Iliffe John Marenbon NIETZSCHE Michael Tanner MEMORY Jonathan K. Foster NINETEENTH-CENTURY BRITAIN METAPHYSICS Stephen Mumford Christopher Harvie and THE MEXICAN REVOLUTION H. C. G. Matthew Alan Knight THE NORMAN CONQUEST MICHAEL FARADAY Frank A. J. L. James George Garnett MICROBIOLOGY Nicholas P. Money NORTH AMERICAN INDIANS MICROECONOMICS Avinash Dixit Theda Perdue and Michael D. Green MICROSCOPY Terence Allen NORTHERN IRELAND THE MIDDLE AGES Miri Rubin Marc Mulholland MILITARY JUSTICE Eugene R. Fidell NOTHING Frank Close MINERALS David Vaughan NUCLEAR PHYSICS Frank Close MODERN ART David Cottington NUCLEAR POWER Maxwell Irvine MODERN CHINA Rana Mitter NUCLEAR WEAPONS MODERN DRAMA Joseph M. Siracusa Kirsten E. Shepherd-Barr NUMBERS Peter M. Higgins MODERN FRANCE NUTRITION David A. Bender Vanessa R. Schwartz OBJECTIVITY Stephen Gaukroger MODERN IRELAND Senia Pašeta THE OLD TESTAMENT MODERN JAPAN Michael D. Coogan Christopher Goto-Jones THE ORCHESTRA D. Kern Holoman MODERN LATIN AMERICAN ORGANIZATIONS Mary Jo Hatch LITERATURE PAGANISM Owen Davies Roberto González Echevarría THE PALESTINIAN-ISRAELI MODERN WAR Richard English CONFLICT Martin Bunton MODERNISM Christopher Butler PANDEMICS Christian W. McMillen PARTICLE PHYSICS Frank Close REALITY Jan Westerhoff PAUL E. P. Sanders THE REFORMATION Peter Marshall PEACE Oliver P. Richmond RELATIVITY Russell Stannard PENTECOSTALISM William K. Kay RELIGION IN AMERICA Timothy Beal THE PERIODIC TABLE Eric R. Scerri THE RENAISSANCE Jerry Brotton PHILOSOPHY Edward Craig RENAISSANCE ART PHILOSOPHY IN THE ISLAMIC Geraldine A. Johnson WORLD Peter Adamson REVOLUTIONS Jack A. Goldstone PHILOSOPHY OF LAW RHETORIC Richard Toye Raymond Wacks RISK Baruch Fischhoff and John Kadvany PHILOSOPHY OF SCIENCE RITUAL Barry Stephenson Samir Okasha RIVERS Nick Middleton PHOTOGRAPHY Steve Edwards ROBOTICS Alan Winfield PHYSICAL CHEMISTRY Peter Atkins ROMAN BRITAIN Peter Salway PILGRIMAGE Ian Reader THE ROMAN EMPIRE PLAGUE Paul Slack Christopher Kelly PLANETS David A. Rothery THE ROMAN REPUBLIC PLANTS Timothy Walker David M. Gwynn PLATE TECTONICS Peter Molnar ROMANTICISM Michael Ferber PLATO Julia Annas ROUSSEAU Robert Wokler POLITICAL PHILOSOPHY David Miller RUSSELL A. C. Grayling POLITICS Kenneth Minogue RUSSIAN HISTORY Geoffrey Hosking POSTCOLONIALISM Robert Young RUSSIAN LITERATURE Catriona Kelly POSTMODERNISM Christopher Butler THE RUSSIAN REVOLUTION POSTSTRUCTURALISM S. A. Smith Catherine Belsey SAVANNAS Peter A. Furley PREHISTORY Chris Gosden SCHIZOPHRENIA Chris Frith and PRESOCRATIC PHILOSOPHY Eve Johnstone Catherine Osborne SCHOPENHAUER Christopher Janaway PRIVACY Raymond Wacks SCIENCE AND RELIGION PROBABILITY John Haigh Thomas Dixon PROGRESSIVISM Walter Nugent SCIENCE FICTION David Seed PROTESTANTISM Mark A. Noll THE SCIENTIFIC REVOLUTION PSYCHIATRY Tom Burns Lawrence M. Principe PSYCHOANALYSIS Daniel Pick SCOTLAND Rab Houston PSYCHOLOGY Gillian Butler and SEXUALITY Véronique Mottier Freda McManus SHAKESPEARE’S COMEDIES PSYCHOTHERAPY Tom Burns and Bart van Es Eva Burns-Lundgren SIKHISM Eleanor Nesbitt PUBLIC ADMINISTRATION THE SILK ROAD James A. Millward Stella Z. Theodoulou and Ravi K. Roy SLANG Jonathon Green PUBLIC HEALTH Virginia Berridge SLEEP Steven W. Lockley and PURITANISM Francis J. Bremer Russell G. Foster THE QUAKERS Pink Dandelion SOCIAL AND CULTURAL QUANTUM THEORY ANTHROPOLOGY John Polkinghorne John Monaghan and Peter Just RACISM Ali Rattansi SOCIAL PSYCHOLOGY RADIOACTIVITY Claudio Tuniz Richard J. Crisp RASTAFARI Ennis B. Edmonds SOCIAL WORK Sally Holland and THE REAGAN REVOLUTION Gil Troy Jonathan Scourfield SOCIALISM Michael Newman TOCQUEVILLE Harvey C. Mansfield SOCIOLINGUISTICS John Edwards TRAGEDY Adrian Poole SOCIOLOGY Steve Bruce THE TROJAN WAR Eric H. Cline SOCRATES C. C. W. Taylor TRUST Katherine Hawley SOUND Mike Goldsmith THE TUDORS John Guy THE SOVIET UNION Stephen Lovell TWENTIETH‑CENTURY BRITAIN THE SPANISH CIVIL WAR Kenneth O. Morgan Helen Graham THE UNITED NATIONS SPANISH LITERATURE Jo Labanyi Jussi M. Hanhimäki SPINOZA Roger Scruton THE U.S. CONGRESS SPIRITUALITY Philip Sheldrake Donald A. Ritchie SPORT Mike Cronin THE U.S. SUPREME COURT STARS Andrew King Linda Greenhouse STATISTICS David J. Hand UTOPIANISM Lyman Tower Sargent STEM CELLS Jonathan Slack THE VIKINGS Julian Richards STRUCTURAL ENGINEERING VIRUSES Dorothy H. Crawford David Blockley WAR AND TECHNOLOGY STUART BRITAIN John Morrill Alex Roland SUPERCONDUCTIVITY WATER John Finney Stephen Blundell THE WELFARE STATE David Garland SYMMETRY Ian Stewart WILLIAM SHAKESPEARE Stanley Wells TAXATION Stephen Smith WITCHCRAFT Malcolm Gaskill TEETH Peter S. Ungar WITTGENSTEIN A. C. Grayling TERRORISM Charles Townshend WORK Stephen Fineman THEATRE Marvin Carlson WORLD MUSIC Philip Bohlman THEOLOGY David F. Ford THE WORLD TRADE THOMAS AQUINAS Fergus Kerr ORGANIZATION Amrita Narlikar THOUGHT Tim Bayne WORLD WAR II Gerhard L. Weinberg TIBETAN BUDDHISM WRITING AND SCRIPT Matthew T. Kapstein Andrew Robinson

Available soon:

Measurement David Hand Ageing Nancy A. Pachana Translation Matthew Reynolds Pain Rob Boddice Modern Italy Anna Cento Bull

For more information visit our website www.oup.com/vsi/ Christian W. McMillen Pandemics A Very Short Introduction

1 1

Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2016 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Names: McMillen, Christian W., 1969- author. Title: Pandemics : a very short introduction / Christian W. McMillen. Description: New York, NY : Oxford University Press, [2016] | Series: Very short introductions | Includes bibliographical references and index. Identifiers: LCCN 2016028234| ISBN 9780199340071 (paperback) | ISBN 9780199340088 (ebook updf) | ISBN 9780199340095 (ebook epub) | ISBN 9780190625214 (online resource) Subjects: LCSH: Epidemics—History. | BISAC: MEDICAL / History. Classification: LCC RA649 .M373 2016 | DDC 614.4—dc23 LC record available at https://lccn.loc.gov/2016028234

1 3 5 7 9 8 6 4 2 Printed in Great Britain by Ashford Colour Press Ltd., Gosport, Hants. on acid-free paper For Olin, Maya, and Stephanie

Contents

List of illustrations xv Acknowledgments xvii Introduction 1 1 Plague 7 2 Smallpox 31 3 Malaria 45 4 Cholera 60 5 Tuberculosis 73 6 Influenza 89 7 HIV/AIDS 103 Epilogue 119 References 123 Further reading 133 Index 145

List of illustrations

1 The plague doctor from the 6 Poster showing the spread seventeenth century 20 of tuberculosis in Paris, Paul Fürst, Der Doctor Schnabel 1917 77 von Rom, 1656 Courtesy Library of Congress, LC-USZC2-4044 2 Cape Town during the third plague pandemic in 1891 25 7 Tuberculosis around the Courtesy Wellcome Library, world, circa 2012 87 London Yale University Press, 2015; Adapted by permission from 3 Children supporting the Macmillan Publishers Ltd, WHO’s smallpox eradication Nature 502 (October 10, 2013) campaign in India, 1950s 43 8 Soldiers wearing masks for World Health Organization, National Library of Medicine fear of the flu in France during World War I 98 4 WHO’s poster for the malaria Courtesy National Library of eradication campaign in Medicine, record 101396929 India, 1950s 56 9 AIDS awareness poster, Central Health Education Bureau, Ministry of Health, 1996–1997 114 Government of India ACT UP Archives, New York Public Library 5 Cartoon about the arrival of cholera epidemics in the 10 Treatment Action Campaign United States, 1883 61 protestors in Durban, South Puck, Illustriertes Africa, July 2000 116 Humoristisches Wochenblatt, Photograph by Gideon Mendel, July 18, 1883, p. 324 Corbis AAKA001780

Acknowledgments

Several years ago Nancy Toff at Oxford and I met and discussed a variety of potential projects. I was then in the thick of working on a book on tuberculosis. Writing that book got me interested in epidemics more broadly. Nancy discovered, much to our mutual surprise, that there was no Very Short Introduction on either epidemics or pandemics. Maybe I could write such a book? With Nancy’s help I did. Thanks, Nancy. Elda Granata at Oxford has been unflagging in her willingness to answer innumerable questions. She has made the process a pleasure. I am grateful to the students in my course Epidemics, Pandemics, and History for allowing me, without them knowing it, to test this material out on them. This book is based on the hard work of the many historians dedicated to making disease central to human history. My thanks to them. Finally, my wife, Stephanie, and our children, Maya and Olin, deserve, as always, my greatest thanks.

Introduction

This book will introduce readers to the rich history of pandemic and epidemic disease and suggest that much of the way we confront such things now has been shaped by the past. This is an unremarkable statement but an important point. For very often history is forgotten or rediscovered only when we confront contemporary epidemics and pandemics, and thus patterns from the past are repeated thoughtlessly.

What are pandemics and epidemics? An epidemic is generally considered to be an unexpected, widespread rise in disease incidence at a given time. A pandemic is best thought of as a very large epidemic. Ebola in 2014 was by any measure an epidemic— perhaps even a pandemic. The influenza that killed fifty million people around the world in 1918 was a pandemic.

A common way to think about epidemics and pandemics is as events. They come and they go. But if we think about them this way, can we call HIV/AIDS a pandemic? Or tuberculosis? What about malaria? Pandemics can be either discrete events or what I would like to call persistent pandemics. Tuberculosis, malaria, and HIV/AIDS, which affect enormous swaths of the globe and kill millions and millions each year, are persistent pandemics.

1 Pandemics develop effective therapies, as well as understand how to prevent therapies, howtoprevent aswellunderstand effective develop that caused plagueallowedmedicineto bacillus andthe bacteria ofthetubercle discovery The beabletocured. might actually what causedagivendisease.Diseases knew medical scienceactually vanished. For fordiseaseetiology explanations time thefirst meantthat centuries-old of diseasessuchastuberculosis asthecause ofbacteria discovery change cannotbeoverstated. The consequencesofthis byone. The explained thereafter forever inmyriad meantthatGermany diseasesonceexplained ways were Pasteur inFrance Kochin withtheworkofRobert andculminated modern medicineinwhichwenowlive.What beganwithLouis that usheredintheage revolution of revolution—a laboratory significant change asaresultofthelate-nineteenth-century identitiesofeachdiseaseunderwent epidemics andpandemics.The of areanumberofthemes andtopicsthat linkthehistory There disease. agaymanageable infection, disease,aheterosexual contingent:each onehistorically adeath sentence,achronicand so muchovertimethat ithastaken onmultiplenovelidentities, in globalhealth.Likewise withHIV/AIDS; itsidentity haschanged in the1970sand1980sasWorld Bankbecamethemajorplayer 1950s whentheWHOattempted toeradicate it;ittookonanother isnovel.Malaria context historical identity took onanew inthe XDR-TB becomenovelagain.Eachparticular emerges—and they change—TB worseinonearea,thenbetter gets inanother; that TB,HIV/AIDS, andmalariaarenotnovel.Buttheirprofiles novelty, contagiousness,andseverity. infectiousness, It mightseem attack rates minimalpopulation immunity, andexplosiveness, eight criteria:widegeographic diseasemovement,high extension, that meet itmust suggested a pandemicisandhasbeen.They thatwhat came upwithabroadframework canworktohelpdefine and Infectious Diseasesat theNational Institutes ofHealth (NIH) at diseasespecialists theNationalinfectious Institute ofAllergy Health Organization (WHO) andothers.In response,several emerged ofpandemicsusedbythe overthedefinition World In thewake ofthe2009H1N1influenzapandemic,controversy 2 Introduction 3 None of this means that drugs and medical research are not drugs and medical means that of this None essential for the control of epidemics. They are, of course. These most has places with persistent pandemics are in what days come to be called the global south. The burden of epidemic leading cause of disease has shifted: tuberculosis, once Europe’s has not disappeared from the earth;death, it has simply moved. effective long before or any therapy TB declined in the West preventive existed; agent it did so because of public health of interventions quality improved and a generally such as isolation in the developing even world life. TB has increased dramatically after the discovery of antibiotics—one of modern biomedicine’s actuallytriumphs—that kill it and cure has done so It the patient. allow it to thrive: unequal access to because of conditions that of infection, and drugs, crowded living conditions, high rates in among other things. TB declined HIV/AIDS, comorbidities like one partof the world without the aid of biomedical interventions and increased in another part of the planet despite them. This between relationship pair of themes: the points to another of epidemics and poverty and the geography and disease diseases discussedpandemics. All of the able in this book, while to be controlled (to varying medicine, are degrees) by modern affected by social conditions. a reason cholera is, there is That more than a century States but ago United disappeared from the is still present in much of the developing HIV/AIDS world, or that disproportionately plague was effects Africa, or that sub-Saharan 1720 than the rich during Marseilles’s worse among the poor the conditions been able to transcend have epidemic. Some places not. infectious allow that while others have diseases to flourish, infections.the laboratory But revolution also cultivated an undue world to rid the biomedicine power of in the of confidence amount of infectious so to do fostered and diseases the way belief the that the than on attacking germs dependent on attacking was far more in the first rise to disease place. gave that social conditions Pandemics virgin soilforsmallpox andotherOldWorld diseases.In theearly Inimportant. consideredIndians early America,colonists tobe of susceptibility—who adisease andwhy—is question gets The invader.exotic itarrivesasafrighteningand north, occasionally inthedeveloped world. Whenitappears a tropicaldiseaseinthedeveloping itisfearedornot. have onwhether aneffect Malaria isnowfirmly including intravenous druguse.Adisease’s placeoforigincan many have perceiveditscausestoberootedinsocial deviance, ofhuman sexuality; caused: HIVistangledupinthecomplexities dramatic howitis sensibilities,disgusting—or and,tomost thoroughly unpleasantdisease,thesymptomsofwhichare wrapped upinhowagivendiseasemanifests—cholera isa is often to occasionmuchconcern.Fearing somediseasesandnotothers killed at fifty millionpeopleinlessthanayear),seems least rarely which hasthecapacity tokilluntoldnumbers(the1918pandemic risk.Yet totheactual pandemic wasoutofproportion influenza, the climate offearintheUnited States duringthe2014 Ebola anti-Jewish century. pogromsinthefourteenth In ourowntime, considerable attached stigma to the disease.Plagueprompted isstill States intothepresent.There intherecentpast—and AIDS inspiredfearanddiscrimination inplaceslike theUnited thosewithHIV/ century; considerable panic inthenineteenth Fear caused epidemics.Cholera anddread characterize withbiomedicine. alleviated andthat willnotbe everywhere conditions that donotexist there isarelationship diseaseandsocialconditions, between simplepoint isthat water very contaminated byhumanfeces. The reasons why millionsofpeopleintheglobalsoutharedrinking cholera hasbeenlifesaving. Butitdoesnothingtoaddressthe inthe1960s,oral rehydrationSince itsdiscovery therapy for rates andinfection arerisinginsomecountries. been uneven, HIV/AIDS.has beenessentialinthefightagainst accesshas Yet therapy,Antiretroviral byany measure, discovery anextraordinary 4 Introduction 5 Epidemics and pandemics cannot occur without a dense and in pandemic of these diseases emerged None mobile population. down to farm and begun trading form until humans had settled from diseases need to be transmitted Infectious with one another. host to host to survive; host must that be susceptible. Smallpox because it was remained such a killer among American Indians once those populations; able, over centuries, to find non-immune and declined. Trade diminished, the disease naturally populations were well developed by the fourteenth century;travel the plague of this. TB exploded allowed only when conditions took advantage The connection between and the epidemics and pandemics As early as the fifteenth is clear. growth of the modern state formed states city the plague, Italian in response to century, boards of health. Thestate-sponsored pandemics of the cholera nineteenth century effortsat quarantine— led to nationwide Measures efforts state. by a central could only be carried off that such as compulsory this connection. also demonstrate vaccination All of these diseases, save smallpox, are still smallpox, with us. Only plague, save All of these diseases, in the which does still occur—there was an epidemic in India outbreaks in Madagascar—has 1990s, and it has regular And new on diseases are surely ferocity. diminished in scope and the horizon. Thus, while much of this book is historical, it is not solely about history. decades of the twentieth century, black South Africans and others and others Africans black South of the twentiethdecades century, could while whites to TB, susceptible be racially thought to were infection.fight than to malaria susceptible were less Africans That colonists to the New led, in part, to their importation as slaves hundreds in the seventeenth For and eighteenth centuries. World the bacteriologicalof years, until revolution, debated many whether or brought on by were contagious or not diseases and vegetable animal rotting bad air caused by miasma—the The plague was oftenfor considered to be a punishment matter. sin. Each of these explanations changed. Pandemics aid tothoseworkingonepidemicsandpandemicsnow. arecordofsuccessesandfailuresthat shouldbean accumulated source material of value We notonlytohistorians. have to them.We have, collectively, anuntoldamountof accumulated causes them,what them,andhowpeoplehave mightstop reacted onwhat about epidemicsandpandemicsforcenturies,reflecting kings,queens,andpresidents—haveepidemiologists, beenwriting government bureaucrats, anthropologists, historians, journalists, Finally, memoirists, poets, novelists, people—eyewitnesses, the spreadofepidemicsandpandemics. World War I.Human, movementarecriticalin animal,andinsect and trade andtheheightenedmobility networks broughtonby could onlyhave builttransportation donesobecauseofthenewly inamatter oftheplanet spread aroundmost ofmonthsin1918,it mobility tomovearoundtheglobe.Whenpandemicinfluenza Europe intheeighteenthcentury. AIDShasreliedonhuman it: thedenselypacked citiesandworkplacesofindustrializing 6 Chapter 1 Plague

Plague. A word more freighted with meaning in the history of disease would be hard to find. It is a disease we now know to be caused by a bacillus, Yersinia pestis, transmitted by the bite of an infected flea—a flea seeking a human host after its animal host died. It first appeared in the sixth centuryce when the first identifiable pandemic occurred during the Byzantine Empire. It is commonly called the Plague of Justinian after the eastern Roman emperor Justinian. Where it originated is uncertain—it possibly came from the interior of central Africa to Ethiopia and went on to Byzantium via well-established trade networks. But it might have come from Asia. We don’t know. It first appeared in the historical record in 541 in the Egyptian port city of Pelusium. It took two years to travel the length and breadth of the Mediterranean, sparing no country along its coast, moving on to Persia in the east and the British Isles in the north.

Although precise demographic data does not exist, it is clear that the pandemic had devastating effects on mortality. John of Ephesus, in his Ecclesiastical History, detailed his encounter with the plague as he coincidentally traveled along its path from Constantinople to Alexandria and back through Palestine, Syria, and Asia Minor. He documented fallow fields, vineyards with grapes unpicked, animals gone feral, and people who spent their days digging graves. The Greek historian Procopius said that

7 Pandemics rag[ed]pestilence farandwidewithfiercedestruction Bede, inhisEcclesiasticalHistory,lamentedthat plague’s “sudden century,finally reachedmainlandEnglandinthemid-seventh a pacethat Whenit itforced theabandonmentofburialpractices. Early Islamic writerschronicleddeath onsuchascaleandat such reachesoftheRomanEmpire. ontheeastern demographic effect thatnoted thenovelty theplaguehadamajor andreported been onelike thePlagueofJustinian. Pre-Islamic Arabic writers plague familiarwithearlierepidemicsagreedthat therehadnever ofthe Procopiusdeadly devastation. andotherGreekobservers impressionof numbersare impressionistic—an capital. These the plaguetookthreehundredthousandlivesinByzantine annihilated.” Evagrius, observer, anothercontemporary thought day “wholehumanrace cameneartobeing in542.The inasingle plague claimedtenthousandlivesinConstantinople These conclusions are based on slivers of evidence, for whenone conclusions arebasedonsliversofevidence, These have been nomatch for good land,royalpower, andvast wealth. in the660s;two generations later it wasthriving.Plagueseemsto lifewashardhitbytheplague negligible. Northumbrianmonastic villages—was mightwellhave shocking.Its long-termeffects been death, theemptying theabandonmentof outofmonasteries, disappeared twenty-three yearslater. Its immediate impact—mass itself. Bycontrast, plaguedidnotreachBritainuntil664; it pandemic mighthave contributedtothedownfallofempire that plague thefirst papyrological, andlegalevidence—suggest gleanedfromcareful attentionEmpire—effects tonumismatic, ofrural depopulationthe effects onthefinancesofByzantine plague’sThe varied fromplacetoplace.Onagrand effects scale, rat hosts. was gone, perhapsnolonger ableto findsusceptiblehumanor it of Europe andtheNear Bytheendofeighthcentury East. Justinian, morethanadozenseparate epidemicsvisitedparts For morethan two hundredyears,beginningwiththePlagueof carried offmany throughoutthelength andbreadthofBritain.” 8 . . . and Plague 9 Europe’s apparently plague-free centuries came to an end in 1347 apparently plague-free centuries came to an end in 1347 Europe’s when plague returned and took with it up to half of the continent’s of the so-called more. When the first wave population—perhaps second pandemic finally fled in 1353, it left a continent in its wake the plague regularly forever After changed. it reappeared in 1347 last European world. Its revisited much of Europe and the Islamic The second plague pandemic was in 1770. outbreak was in Russia What we do not know about the first pandemic overshadows what we do not know about the first pandemic overshadows what What tools of analysis as more sophisticated change we do. This may Careful reading of textual sources can get us become available. from disciplines such as will need to draw Historians only so far. and molecular biology of the if the mysteries archaeology, zoology, first pandemic are ever to be revealed. The impact felt in the short keenly of the plague was and long Ships infestedterm in Syria. from Egypt with plague arrived in it there the ports542 at From and Antioch. of Gaza, Ashkelon, of John know from to Damascus, south. We then spread traveled struck then on, plague devastating. it was From Ephesus that the short Syria every In seven between or so years 541 and 749. term, high mortality and mass flight left places empty. many outbreaks had a deleteriousOver the long term, repeated effect on agricultural production of settled populations and the communities. The prevented of Arabia the plague mobile lifestyle in turn increased the power of nomadic from taking hold and of agricultural The productionpopulations. continued fragility meant a reduction a pastoral in crop-based taxes and the rise of was plague in Syria and so devastating So frequent were economy. Syria developed Islamic times that a reputation its effects by early plague. Theas a land riddled with impression stuck. By the had a Syria was well known as having medieval period Islamic long and disastrous experience with plague. tries to look beyond monasteries and into life more generally, look beyondtries to monasteries life more generally, and into documentationdisappears. Pandemics of GalenandHippocrates, translated vianewly Arabic renderings ofthewritings Death—a timewhenthelate rediscovery medieval century.nearly theendof thenineteenth DuringtheBlack contagion—would dominate theoriesofdiseasetransmission until with cholera, miasmaand theseexplanations—especially As providence, miasma,contagion, andindividualsusceptibility. overlappingways: inseveral howwasexplained people dying?The Europe. It How demandedanexplanation. andwhy weresomany of Kaffaandspreadinexorably across 1346 intheBlackSeaport recordin It appearedinthe historical first and thecountryside. For thecity yearsplagueswept acrossEurope,devastating seven uniquely deadly. It wastheBlackDeath. what washappening.Itprepared; nooneknew wasnoveland None pandemic. ofthiswassoduringthefirst No onewas disease. afamiliarandincreasinglywell-understood experienced as cataclysmic astheplaguemighthave beeninthe1660s, London, andnovelevent; anew Florenceexperienced example. London, for wereforthe1665–66plaguein different thanthey toandconsequences ofplagueinFlorence1348were reactions ways aresult, it,anddeveloped ofdealingwithit.As to expect came Over thecenturiesEuropeansadaptedtoplague,even suchasDubrovnik. European ports Europe at trade and atime of robust relations Asia between themto and domesticated animals,whichwouldthentransport The fleaswouldthenjumptohumans forfleas. widespread host gerbil andbecameahighlymobile, populationAsian exploded Europe againandagain.Whentheclimate warmed,thecentral It ispossiblethatold modelmightneedrevision. plaguecameto that the andepidemicsofplagueinEuropesuggest central Asia research intothecorrelation changes between intheclimate in areservoir. andthenestablished century fourteenth Recent inthemiddleof plague wasintroducedoncefromcentral Asia scale, andscope.For scholarshave decades,most that believed itwasaseriesofepidemicsthat variednot oneevent; inseverity, 10 Plague 11 This conjunction, with other earlier along . . . Many reacted Boccaccio so in horror to the plague, as Giovanni Many vividly documents in The Decameron. Based on Boccaccio’s conjunctions and eclipses, by causing a deadly corruption of the Jupiter and When air around us, signifies mortality and famines.” pestilence this caused a “great came together, in particular, Mars, ignited drew out of the earth; vapors Mars Jupiter in the air.” them. But even with this scientific one driven by explanation, observation and theory and devoted medicine to the notion that in controlling the disease, plague was still a role ultimately played must pestilence the fact not overlook any that caused by God. “We can thereforeproceeds from the divine will, and our advice only be to return humbly to God.” These earthly explanations for plague’s path were subsumed in were path These earthly explanations for plague’s the plague: God’s cause of most thought was the ultimate what the Before plague reached him, Ralph of Shrewsbury, wrath. Toward his flock to pray. implored and Wells, bishop of Bath of 1348 he wrote, “Since a catastrophic the end of the summer pestilence from the East has arrived in a neighboring kingdom, devoutlyit is very and unless we pray much to be feared that a similar pestilence will stretch its poisonous branches incessantly, down and consume the inhabitants.” into this realm, and strike one of the Divine explanations augmented by others. In were most detailed contemporary explanations, the masters of the wrote in October the “distant 1348 that Paris faculty of medicine at and first cause of this pestilence was and is the configuration of the heavens. of Greek and Latin texts, was in full flower, and the notion of bad the notion and and Latinof Greek texts, in full flower, was not as were and contagion flourished—miasma disease air causing might theyanother as to one opposed People would become. become infected up out of air seeping of the miasmatic because gases. toxic released its vegetable matter as rotting the ground They the disease on to and able to pass would then be contagious sinners and susceptible such as those uniquely others—especially the gluttonous. the licentious and malcontents, Pandemics Florence responded by creating sanitary commissions.ToFlorence responded bycreating sanitary ensure Despite thehelplessness many felt,citiessuchas Venice and as onethousandJewish communities acrossEurope. Some searchedforscapegoats. Mobs wipedoutperhapsasmany world runningfromGod’s will wasconsideredblasphemous. in thefaceofsuchdeath, many choseflight,but inthe Muslim abreakdown oforder. term,suggest at intheshort least Helpless plague pitsthat burialritualsand, were anaffronttoestablished one another. In city city after thedeadwereburiedenmassein family memberstreated theirsicklike dogs;neighborsshunned follow.” alloftherest almost Suspicionand fearwererampant: that whenonememberofafamilydies, beenobserved has often with anyone whosekinsmenorkinswomanhasdied,because it [meant] thatmortality forfearofdeath men[did]not darespeak thediseasetraveleddead. As throughFrance, the“scaleof population ofAvignon perished;inMarseilles fouroutoffivewere of thecity ofFlorence.” AFrench notedthat halfthe observer within the walls hundred thousand human lives were extinguished July oftheyearinquestion thatman) wassoimmenseanddevastating March between and cruelty ofheaven (andpossibly, insomemeasure,alsothat of human beings.” hadsuchacalamity Never “The before struck. take careofthem,Boccacciowrote,died“morelike animalsthan outside thecity withoutmedicalcareorfamilycommunity to alivetoenforcethem.Those left andman;therewerefew God causedbyplagueledpeopletoabandonthelaws of misery The power ofmedicinewereprofitlessandunavailing.” were unavailing. “in thefaceofitsonrush,allwisdomandingenuity ofman righteous anger at ouriniquitousway oflife.” thecause, Whatever bodies,” oritmighthave been “punishmentsignifying God’s on thecause—itmighthave beenthe“influenceofheavenly representation oftheplague’s reception.Boccacciowasagnostic inFlorence,TheDecameronisanunparalleled literary experience . . . All oftheadvicephysicians andallthe . . . it isreliablythoughtthat overa 12 Plague 13 People who lived through the Black Death reacted lived through the Black Death who in numerous People they to explain tried ways: they the catastrophe; in horror; reeled they difficult is more outsiders. What blamed they away; ran term effects on to discern are the longer the Black Death of social customs, culture, and so religion, the economy, demography, portion a significant decimated the near term, the plague forth. In of 60 percent is that recent estimate of the population—one leading to low for a century, stayed Europe perished. Population and the combined with inflation, labor shortages, higher wages for a time, some changed, opening of more land. Depopulation This is best documented aspects the social and economic order. of the dearth of laborers Abbey, Eynsham 1349, at in England. In to enter into a newforced the abbot and the lord of the manor terms. more favorable labor agreement with the tenants with far of Earl de Vere, of John 1351, the unfree peasants on the estate In On yet Oxford, were relieved of their obligations. another of many in Cheshire, rents were the royal manor of Drakelow estate, John according to the accounting official, lowered by a third “due,” “to the effects of the pestilence. The tenants de Wodhull, tenements left the lord’s would have (which to leave threatened unless they such a remission, to last until the were granted empty) be worthworld improves and the tenements came to more.” went up, but so too did the cost of almost all basic goods—a Wages of goods. also meant a scarcity demand for labor based on scarcity response to demands for lower rents and higher wages, In that the air was pure, they was pure, the air that of sewers the cleaning enforced and the collection on its way plague was seemed clear When it of garbage. Genoa from or Pisa traveling those forbade city the to Florence, arrive, sanitary When plague did from entering. regulations and infected sought to effect of all “putrid matter removal the of the or be induced a corruption which might arise persons, from These ineffective. measures were largely it Plague came and air.” a century would be killed. It remotely before or more anything effective of the could be put in place—and by then the virulence anyway. plague had diminished Pandemics chronicler Matteo girlsandunskilled Villaninotedthat “serving in Italy demandedhigher wages,Laborers too. In Florence, the nootherchoice. epidemics in1360–62and1369, therewasoften madeworsebysubsequent the faceofacontinuedlaborshortage, demanding andpaying wages, wascommon:in excess thepractice Black Death. Despitethepresenceoflaws forbiddingboth the theirstation inlife,werecommonthedecadesafter knew whenpeople markedly fortimespast, changing.Lamentations that peasantbehaviorestate anddegree”alsosuggest was “outrageous their apparelofdiverspeopleagainst andexcessive appearance ofhiminhisclothes.” laws at the directed Sumptuary to imitate theways ofthefreemen,andgiveshimself the areservants andmasters are nowmasters happy timesofoldhave beenrudelywipedout.” Because“servants was theworldofsuchfolkwell-orderedinitsestate.” Butnow“our clothingwasplaingrey. any thanthis.Their otherfeast they Then was water. tothem;rarely cheeseandmilkwereafeast had Then their breadwasmadeofbeansandothercorn,drink toeat wheat bread; labourers ofoldentimeswerenotaccustomed John poet The lamentedthepassingofoldways: Gower “The enclavehunting—once theexclusive oftherich. befitting alsoincreasinglytookup station their inlife;they surplustopurchaseclothesnot usedtheirnewfound They bearsthisout. the (muchmaligned)behavior ofthepeasantry on there wasaperceptiblechange inmentalité.Elitecommentary century Death andinthesubsequentdecadesoffourteenth that intheimmediate suggests oftheBlack aftermath necessary lawsThat seekinghigherwages against andlowerrentswere attempted totake advantage ofthecrisis. thosewho against swiftly thegovernmentshortage, acted Facingwork, andpunishthosewhodisobeyed. labor asevere wage limits,compelpeopleto in1351toset Statute ofLabourers Parliament in1349andthe passedtheOrdinanceofLabourers 14 . . . the peasant pretends the peasantpretends Plague 15 Europe’s demographic decimation was a short-term decimation shock. Within demographic Europe’s productivity and population a centurythe continent’s much of two rebounded and even nearly take flourished. But it would levelshundred years for pre-plague population to be reestablished it would not happen in over much of the western Mediterranean; decline did not have the population England until after Yet 1600. a long-term adverse effect. the One possible that is explanation reached a Malthusian might have pre-pandemic population their carryingcritical mass where resources had reached capacity. in the short term, while a tragedy the Black Death, this view, In was perhaps, viewed time horizon, beneficial. over a longer The well-documented all of Europe in the across increase in real wages century after might best be explained Death the Black by the in the economy changes Attributing increased premium on labor. of space to a single cause, swath of such a large and demography generalizations devastating, how Even is not possible. no matter taking already begun have may changes Many are hard to make. places, was declining here and there; in many place: population before change and land tenure were undergoing labor relations the Black Death—serfdom disappeared from Flanders and Though is difficult it howgrasp on precisely to of standards get a is hard, if not impossible, to data changed—the living might have both men and women in the that likely come by—it does seem off than their were better decades after ironically, the Black Death, counterparts in the decades of want preceding the plague. women with no experience with no women in service least and stable at boys want 24 most and the or them 18 among arrogant per year, 12 florins artisansand minor nurses and so also working per year, florins and laborers nearly the usual pay, three times or with their hands want to work the best and all seed, and all want oxen on the land That more these demands were to abandon all others.” lands, and few wishes of a than the disgruntled one sees the is clear when people to and force to cap wages attempts official responses: the terms. matter accept employment no Pandemics devastating as the Black Death meant that there was much less less much astheBlackDeathdevastating meantthat therewas againabrutalandshocking continent-wideconflagrationnever as Ottoman takeover in1517. Its that regularity therewas andthefact theBlack Death eighteen majorepidemicsbetween andthe to nineyears,andinSyria-Palestine thereappeartohave been passed inFrance eight without plague.In itappearedevery Egypt, 1665. For nearlythreehundredyears—1500 to1720—not ayear 1500and outbreaksbetween sufferedseventeen places. London toplagueasitbecamearegularfeature oflifeinmanyaccustomed roleinmanagingtheplague.Peopletake amoreactive became declined,and more confidence,mortality governments beganto In gained theBlackDeath, doctors thedecades andcenturiesafter to buildingsmaller, churches. moremodest their founding.In England,grand gave cathedral construction way consequent lapsesinlearningbroughtonbytheplagueinspired intheplague’sexpanded andthe ofpriests dearth aftermath—a awareness ofmortality. oftheunpredictability Universities anewfound A fascination suggests withthe macabreinartwork end tooppressionbytakingfromtherichandgivingpoor. wasonhisway toputan andprofessingthat toearth Christ clergy among otherthings—begantakingontheconventional rolesofthe bywhippingthemselves, theiruniqueformofpiety performed Central whopublicly Europeanflagellants—religious devotees ofthechurch. thestrictures places, aswellrebellionagainst worship. In thewake insome ofpiety oftheplagueweseeanexcess amarkonliterature,and art, A catastrophe ofsuchascaleleft wasanaccelerant. it certainly undeniable isthat iftheplaguewasnotsingularcauseofchange, ofbodiesinthewake oftheplague?dearth Possibly. What seems proliferated; firearmsdidtoo. Were thesetoolsaresponse tothe innovation. Power-generating suchaswindandwater mills devices andmoreoftechnological acentury Black Death jumpstarted from theplagueat all.Butontheotherhand,itispossiblethat the Holland centurieswithnoassistance inthetwelfth andthirteenth 16 Plague 17 Methods of control changed as doctorscontrol changed of less and less understood Methods or the wrath the origins of the plague to be found in God’s alignment of the planets. They sought more earthly explanations and and they tried to cure fourteenth it. By the end of the century, increasingly in the fifteenth, doctors began to see the plague as beneficial practice. to their of clinical The wealth that experience came from experimenting cures with various is well documented medieval period in the late emerged in a new that of writing genre devoted to explain plague: the plague tractatus. Because some people had time to get to minor, epidemics were comparatively circumstancesknow the disease in less anxious and terrifying than been possible during a major epidemic. The newfoundwould have they to claim that ancient had surpassed confidence led many and Galen, asserting these that masters such as Hippocrates former authorities had no experience with the disease they themselves now mastered. fear and very little scapegoating; in contrast to the innumerable innumerable to the in contrast veryfear and scapegoating; little the next during Death, the Black during century Jews on attacks The extreme the Black shock of in Poland. was only one, there did not return;Death Medical normal. became horrifyingly plague doctors to in their ability gained confidence and municipalities While no one knewconfront it. just plague would when or where as one historiancome—it possessed, it, an “inexplicable has put reveal did begin to itself: first, it broad pattern randomness”—a struck ports; to the it next then from the city moved inland, and in some neighborhoods and not cities, it appeared In country. random. house to house, seemingly at others; it moved from Flight was common. became discernible. of behavior Patterns times, a for self-preservation at meant, So was an urge that Generally remained disregard for others. governments speaking, intact, order. plague did not spell the end of the social and health plague—government-sponsored Official responses to pestboards, hospitals, and as well as the machinery houses, of of early across much the state quarantine—strengthened modern Europe. Pandemics any othersuch imagined causes,whichwerethe breedersofthese or blindfortune, ofwitches, oryet practice malicious anddevilish of theair,infection distemperature inmen’s bodies,muchlessthe He explanations. had notolerance forearthly intoned,“It wasnot much present.Some,like theEnglish preacherRichardLeake, very wasstill accompanied by miasma.AndGod Europe wasoften ofcontagionthat begantoemerge inearlymodern theory The proof.” and theseaforementionedcategories arethedemonstrations of andbyunanimous reports, thesenses,observations, deduction, ofcontagionhasbeenprovedbyexperience, existence answer: The already thedivinelaw the notionofcontagion,wewill hasrefuted ofcontagion, when “If itwereasked, howdowesubmittothetheory common Muslim wrote, sentplague.Ibnal-Khatib that belief God in favor ofcontagion.Hiscontrast withthemore wereinstark views declarationsArabic offeredoneoftheclearest writerIbn al-Khatib as theBlackDeath waswreakinghavoc intheMediterranean, the century.be contagiousappearedasearlythelate fourteenth Just in Europethesixteenthcentury. notionthat plaguemight The it gainedlittle itbegantocatch on overmiasmaandGod; traction Renaissance; alongtheway intheArabic itstopped world,where ofcontagiousseeds,tothe atheory from Galen,whodeveloped ideaofcontagionhasalonghistory.The It followedatwisted path built upsomeimmunity. aspopulations disease itselfwasbecominglessandsevere need forisolation ofpatients. Butit isalsopossiblethat the ofthediseasesuchas understandings surely camewithnew confidenceinmedicine.Someofthis the newfound clearlycorrespondswith very inmortality marked reduction The such asMarseilles, Padua, andMilan. Mostly, declined. mortality outbreaks tookupwardsof30percentthepopulations ofplaces perishedin1656–57,population ofGenoa andat sixother least wereseriousepidemics—up to60percentofthe again. There theBlackDeath, lossoflifeonsuchascalewasnotseen After 18 Plague There thus sent out seeds are . . . 19 evils, but the mass and multitude of our sins.” Plague was God’s was God’s Plague evils,sins.” of our and multitude the mass but in the Tuscan Lupo, Monte of village tiny the In punishment. of 1630. Secular in the fall arrived plague hinterlands, and religious causes and over its along Religious leaders, cures. battled officials Godwith most wanted to placate of the townspeople, a with Secularreligious procession. believing health officials, plague that to restrict and gatherings such public attempted was contagious, Spain violence ensued. In their families. Riotous the sick and isolate and Trincavella, Vetorre Valles, such authors as Francisco and Italy plague passed suggested diseases like that Girolamo Fracastoro put it in his commentary on Asfrom person to person. Valles contagion or disease can occur Epidemics, “No without the Galen’s of somethingtransmission from the already infected person to the person who is being infected. That is agreed, since every action occursnatural by contact. The (incomplete) shift toward belief in contagion manifested itself of both people and goods, and isolation in a move toward quarantine restrictions, such as on public gatherings prohibitions travel power over increase of state religious processions, and a general northern the individual lives of the sick and suspected sick. In of health where these measures were pioneered, boards Italy, times of plague. They regarding public health in enforced laws effect; plague still came. had little of contagion, which are some sortof contagion, which are of defilements, from the sufferer But early be affectedto the person about to by the contagion.” modern views of contagion were very ones. different than modern writing in 1636, an English commentator, Stephen Bradwell, mixes contagion and miasma without compunction, for they are of explaining this stage other diseases), not, at plague (and mutually exclusive: as he wrote, “That which infecteth another by touching it, whetherwith his own quality the medium of the The infectious touch be corporeal or spiritual or an airy breath.” that was a “seminaryagent tincture full of a venomous quality, and pierces being very spiritous mixeth thin and itself with the air, the pores of the body.” Pandemics are always attacked thelast byacontagion, onaccountofthemeans state bypersons ina ofopulence andsuch and inhabitedchiefly arewide,the housesarelarge, streets wealthy neighborhood:“The of plagueinMarseilles in1720, had thistosay onedoctor abouta upon thepoorthanrich.Writing major outbreak duringthelast unnoticed inItaly, France, more andEnglandthat plaguepreyed emerging association anddisease.It poverty between didnotgo mighthave andreinforced,however,What they reflected was an maskfilledwithherbsto ward offthepestilence. protective 1. This 1656engravingThis wearinga showstheiconicplaguedoctor 20 Plague 21 Not all states adopted quarantine with equal vigor. Those that with equal vigor. adopted quarantine all states Not as to the sources of plague. Just did were in closer proximity to ability important between a state’s was the growing association its people free from epidemics. This to keep and its ability govern was most powerfullyassociation Italian felt in the independent sixteenth century and was in full flower by the late city-states Italy’s was engulfed by the plague in 1575–78. when all of Italy Plague’s contagious nature also had an effect also had nature contagious on commerce as Plague’s Maritime on goods. sought to impose quarantine European states when it was fourteenth back to the late century, dates quarantine first imposed in the port of Dubrovnik. Over time it became and not necessarily effective.routine, if controversial Quarantine people, too, could be, and often alone; to goods was not relegated the and were, detained. The travel, between trade, association plague was longstanding. Because most believedplague that infectious, it was in some way had come from the east and that partdetaining and people from that of the world had an goods was hard to resist. Theappeal that same was not so in the Muslim was far less well accepted, and the world, where contagion necessary capacity administrative did not exist for quarantine in and China, invoked other commonly Empire. India the Ottoman was thus It either. sources of plague, did not practice quarantine to police particularlyup to European states, in the Mediterranean, their own borders. The arrived from the east disease sense that to curtailand the belief nothing was being done that its movement would only hasten the divide between east and west—a divide of the pandemics during the cholera would grow stronger that nineteenth century. they have to place themselves out of its reach.” At a time when a time when At reach.” out of its themselves to place they have poor, of the and a disease contagious was thought plague many began to worrythe wealthy between about its passage increasingly took on meaning problem. It Plague became a social the classes. the plague of Fear of the divide betweenas a symbol and poor. rich in hand. the poor went hand and fear of Pandemics after that Moscowafter Europeanepidemic. It thelast visited hosted appearance EuropeinMarseilles.its last inwestern Fifty years Half laterit killedeighty itmade thousandLondoners. acentury timein1665–66,when PlaguevisitedEnglandforthelast return. outslowly,petered leaving oneplaceandthenanother, to never same cannotbesaidaboutthefinal yearsofthepandemic. It rather preciselyto1347 andthearrival oftheBlackDeath, the If thebeginningofsecondplague pandemiccanbedated enlightened time. asitincreasinglybegantoseemlike aholdover fromaless century commerce wouldcomeunderconsiderable fireintheeighteenth on them. Quarantine asapublichealthmeasureanditseffect disregarded orderstostay put,andthereweresimplytoomany of of thesickwasagood itdidlittle: idea;inpractice plaguevictims epidemic inmorethanacentury. In theory, householdquarantine suffereditsworst twowork, forthat year andintothenext London plague madeitsway Countries,itdidnotalways fromtheLow London as asitwasin1664 maritime quarantine wasineffect, larger provedchallenging.Even andmoreheterogeneous, when suchanedificein Erecting protection. France, whichwasmuch populations tocivicprideand that forcenturieshadbeen devoted livelihood. Further, theItalian city-states weresmall,with ontheir restrictions and thepowerofmerchantstosubvert temperedbylaxenforcement,porousborders, wereoften effects stateat control overepidemics,the Despite theseearlyefforts common. quarantine andisolation, especially, becamemoreand inEngland’sis evident plagueordersfrom1578—and first inEurope—Italy’s begantocatch onelsewhere methods influence where therehadbeennoneinitiallymadeItaly unique.Butits boards epidemic, andthecreation ofmoreandsanitary outside—increased knowledge regardingthesourceofan control overthemovementofpeopleandgoods—especially from tocontrolplaguethroughimprovedsanitation,strict efforts 22 Plague 23 When pandemic plague reappeared in the 1890s, historicalWhen pandemic plague reappeared in the memory The had not vanished. nineteenth-century experience experienced reminded those countries that with pandemic cholera it meant to deal with epidemic disease; most of the plague what had been developed deployed against cholera strategies during the And so, in influence loomed large. second plague pandemic. Its in turn, did experience influence the ways with pandemic cholera managed. which the third plague pandemic would be Egypt over and over again throughout the eighteenth century, Egypt century, the eighteenth throughout again over and over of three population of Cairo’s as 20 percent as many killing persisted It 1791. epidemic of the major during thousand hundred more For well into the nineteenth Empire century. in the Ottoman affectedcenturies plague had than three religious beliefs and and the as demography as well disease transmission, theories of first it ushered in the health public state-sponsored economy; across the early at looked When And then it was gone. measures. petered gradually out— appears to have modern world, plague last after all, it was more than a century between London’s the locally or at at But when looked epidemic and Moscow’s. England country disappeared suddenly. level, to have it appears plague regularly since the 1340s. Thenhad been visited by the it in 1665–66 and never appearance made one last dramatic after centuries in which no returned. The same is true of France: the was in 1720 the epidemic in Marseilles year was plague-free, developed immunity, have may happened? Rats last. What the dominant species of or perhaps stopping plague in its tracks, fluctuations central in the climate Asia that Perhaps changed. rat reintroduced plague time and again ceased. Further, might have was not effective, cases quarantine despite the fact it in many that slow down to gradually over the long term it worked might be that the movement of the plague. After began to strictly 1666 England plague neverenforce quarantine; returned. But because plague different diverse places and ended at lasted for so long in so many times, it is not possible to determine a single cause of the disease’s demise. Pandemics possible by rapidly developing globaltradepossible byrapidly andhuman networks developing pandemic’sThe coursearoundmuch oftheglobewasmade fast months. epidemic burnedoutinafew the citizenry. aresult,masspanic wasavoided, As andAlexandria’s andcooperation localleaderstogainthetrust officials enlisted of publichealthmeasures, forcing peopletoadherestrict handedness, tocontainplague. In rather than Egypt, Alexandria, withbrutality andheavy-were putinplace,sometimes maritime quarantines, oftheseandmore isolation of victims—all systems, Surveillance health measuresweremorerobust. lower—the diseasemighthave beenlessvirulent,andpublic ofIndia, exception With theimportant wasmuch mortality oftheBlackDeath. thirdplaguepandemic was notthereturn The in 1910. adeadlyformofpneumonicplaguebroke China out northeast French colonialmanagement ofthecountry. In Manchuria in pandemic in1914, yearsplaguechallenged thirty andforthenext tothethird killed nearlytwelve millionpeople.Senegalfellvictim India,made itswayandwestern acrossmuchofnorthern whereit inSanFrancisco at theChinese directed andHonolulu. Plague populations; harshmeasureswere black AfricanandChinese racial policiesdesignedtomanagemeans toputintoeffect the Hong Kong;inCapeTown quarantine becamea andSydney relatively low, fearandpanicwerehigh—eighty thousandfled commercial activity. inthesecitieswas Andwhilemortality In Portugal, Oporto, maritimequarantine thecity’s stopped plague.SodidRiodeJaneiroexperienced andBuenosAires. cities. CapeTown, Sydney, Honolulu, andSanFrancisco all spread aroundmuchoftheworld,concentrated inport mostly ForKong andbeyond. ofthedecadethirdpandemic therest Guangzhou. From thereittraveled toHong distance theshort Guangdong andthensouthernChina’s largest trading city, year,That plaguespreadalongtheCanton River, reaching in1890. thirdpandemicbeganinsouthernmainlandChina The 24 Plague 25 Convicts work to sanitize Cape Town during the third plague during Town work to sanitize Cape Convicts Plague returned in the midst of the laboratory revolution. At the a very pandemic in 1894, Alexander beginning of the Yersin, a Japanese scientist, and Shibasaburo Kitasato, Swiss-French discovered the plague bacillus working independently, researcher, its way as the pandemic made Next, of each other. within ten days French around the world, so too did the idea—firstby proposed in Simond while working in Bombay scientist Paul-Louis migration via ever via fastermigration steamships and an enormous increase in and lines. Therail between commerce, migration, relationship epidemic infectious disease—and the need to develop means of to deal with the problem—had been cooperation international evident throughout the nineteenth century as a result of pandemic The became clearer when plague returned,cholera. relationship pandemic influenza and would be made so again in 1918 when circled the globe. 2. pandemic in 1891. Pandemics places that experienced plague in the past hadconsiderable plague inthepast places that rat experienced that many,called buboes.It certain isalmost ofthe ifnotmost, presence ofthetelltale swellinginthearmpits, groin, andtheneck rely on similarities:thesymptomsare thesame,especially whothinkthat thetwoThose diseasesareoneandthesame cannotbethesamedisease. that they stark enough differencesare and premodern,pre-labplague. The plague modernpost-lab caseisbuiltondifferences between Their ofmassrat noevidence death. symptoms insomecases,andalmost plague soquickly. pointtotheabsenceofplague-like They could nothave tospreadthe traveled as wasnecessary asfast claimthat possibledifferencesinvirulence;they ratsand stress Yersinia say arenot andbiologists pestis?Somehistorians they in1665wasthesame diseasenowknowntobecausedby London disease that in542,Avignon visited Constantinople in1349,and diagnosis.How ornotthe retrospective canweknowwhether way new ofseeingplaguepresentedtheproblem of The toolongitwascalledYersiniaBefore pestis. ofthediseasewouldbeimposedonpast. understanding modern,lab-based plague.The cause ofthemedieval symptoms. BothYersin andKitasato claimedtohave foundthe byits identifiableinretrospect turnedintosomething the past the identification ofthebacillusthisallchanged, andtheplagueof hadbeenunseeableandunknowable.After since thesixthcentury thing; thediseasethat hadbeenravaging humanpopulations knowable,ifnotquitetangible, microscope in1894wasadefinite, that camebackinthe1890sandwasidentifiedunder basicandrather suddenway:disease. It didsoinavery theplague Discovering theplaguebacilluschanged theidentity ofthe centuries, cametoanend. transmitted, writingontheplaguefor whichhadpreoccupied rats. Debates plagueandwhy overwho gets andhowitwas 1898—that plague wastransmitted throughfleaslivingon 26 Plague 27 The Venice conference marked an unprecedented level an unprecedented conference marked of The Venice The consensus on the part community. of the international president of the London Epidemiological Society called the on the part advance the nationalities of “a great convention and truly scientific conception of the means toward a truly liberal to be adopted by respective for the prevention governments and to contain the disease with Trying control of infective diseases.” and more effective as more means fell by the wayside quarantine of surveillance and reporting were put in place. If information whereabouts was known, targeted responses about the plague’s restrictionssuch as immigration the site of or port at quarantines than restrictivethe outbreak could be launched rather Plague’s relationship to commerce had of course been well known to commerce had of course relationship Plague’s as a result of the in the 1340s since its first appearance Genoese 1850s to the end of the nineteenth the the east. with From trade to deal century attempted community international an emerging with the spread of infectious a series of regularly diseases at Sanitaryoccurring Conferences. When the third International had reached scientific internationalism plague pandemic arrived, Sanitaryan apexInternational of sorts, exemplified by the where the newest scientific in 1897, Conference held in Venice about plague met desire for loose knowledge a deep-seated restrictions Science could serve on trade. commerce. and flea populations. Like modern plague, plagues of the past—to plagues of plague, modern Like populations. and flea the extent can be certain—first we by sea, way made their suggesting Also, supporters on ships. the agency of the rats of plague theory and thus it change, can contend, the pathogen in some different plagues of the past looked that is no surprise third pandemic. So during the than the plague identified ways most historians, geneticists, and By now, was the disease? what molecular biologists support has always the plague the idea that the emerging evidence. One reason for this is pestis from been Y. well as from as from antiquity, in graves sources originating DNA medievalperiods. and early modern the late Pandemics century Indiancentury history. toWesterncaused thegreatest resistance medicineinnineteenth- isolation ofthesick— andthestrict examinations; postmortem rituals; conventions werenotfollowed; forbiddingfunerary removal tomuchfearedhospitalswhere,amongother things,caste And thosepolicies—fumigation andburningofhouses; forcible influence overpolicy. anunusualamountof experts andsanitary allowed doctors authoritymedical scienceanewfound ascolonialadministrators isturngave thought mightwork.This they whatever license totry gave act authorities measures.The gatherings, andsanitary ontravelneighborhood quarantines, restrictions andreligious colonial officialstotalpowerovershipboardinspections, demands that plaguefromspreadingtoEuropegave Britain stop needtosatisfy international The 1897 EpidemicDiseasesAct. intothedailylivesofIndians, inthe intervention culminating withand of interference wasanunprecedentedlevel reaction medicalscience’sinto question The initial confidence. newfound the Britishcolonialstate’s ability tomanage thedisease andcalled pandemic. From itsarrival inBombay in1896,plaguechallenged India, farandaway hitduringthethird hardest thecountry relationship scienceandcommercewasclearin between The inplace. world bothofthesepolicieswereonlyunevenly andnotification. Acrossthe meansofdiseasesurveillance robust anda reform tocontrolplague:sanitary agreed werenecessary relied onbothlocalcapacity inthetwo andinterest thingsmost ofcourse This ofdeparture. plague at onstopping theports focus toratsshifted asthecarrierofdisease,whichinturnledtoa later, at a1903conferenceheldinParis. had Bythenthefocus heldsixyears consensus still The saw lifted. trade restrictions soon thosethat did,like cordonsaroundports—but Egypt, military toolder,Spain resorted illiberal meanssuchasineffective distinctly nations adheredtotheconferenceconventions—Portugal and clampdowns inspiredbyfearandlackofknowledge. Not all 28 Plague 29 After this change, even in Pune, where the mostAfter even serious resistance this change, in Pune, between had occurred, a spirit of cooperation emerged there Indian Plague and colonial officials. When the Indians Commission issued a report the shift in 1900, it noted that from had been effective. the resistancecoercion to conciliation What brought into starkrevealed relief and the new of cooperation era that Western medicine, a realization was a lack of confidence in the actually did not have the British, despite their bluster, again would theyanswers. Never be able to impose their views on of in such a fashion. The suggestion this was the dawn that India would be belied by future and equality of cooperation an age The the British colonial that point is developments in India. authorities’ initial handling of the plague revealed only a state use of force that capable of imposing its ideas by force. When The the plague authorities were forced to relent—fighting colonial the use of military colonial capacities; and the populace strained than working with rather force proved counterproductive. Perhaps The sanitary might be better. population against the Indian “experience realize that commissioner came to is beginning to be practically may is medically desirable what show that, impossible, and politically dangerous.” , an English-language paper published in Pune, in Pune, paper published , an English-language TheMahratta had neverthe British that wrote “interferedsuch and in largely so domestic, with the of religious habits social and way a systematic practices, most One of the the which spurred hated the people.” most violent reactions,removal especially the isolation, was family was the so resented Pune, camps. In quarantine of women to practice of examining in the streets women and the frequent the plague that houses by British soldiers searching of The 1897. in June C. Rand, was assassinated W. commissioner, after even put in place, more measures were following year, out all across northernresistance a head: rioting broke reached as a reaction and to household searches, segregation, India hospitalization. Pandemics reached pandemicproportions. again Butithasnever exists. ancient andfeareddiseasestill in twenty-first century Madagascar remindtheworldthat this outbreaksinthe1990sIndiaof AfricaandAsia; andin theearly Itit iscontagiouscanspreadfast. haslingered fordecadesinparts be treated bedonequickly, withantibiotics, thismust andbecause burning out.Butplaguehasnotdisappeared.Althoughitcannow By World War Ithethirdpandemicwaseitherundercontrolor tobe. purported asthey were notaspowerful that the colonialstate andWesternfailure, itwasevident medicine backfired andtheBritishwereforcedtocometermswiththeir 30 Chapter 2 Smallpox

Until the World Health Organization declared the globe to be smallpox-free in 1980, it had been an endemic and pandemic disease for most of the last millennium, and possibly longer. Evidence from Egyptian mummies is tantalizing but not definitive; it is possible that the Plague of Athens, beginning in 430 bce and so memorably described by Thucydides, was caused by smallpox. It has killed hundreds of millions of people. The earliest and clearest description of smallpox comes from the fourth-century Chinese alchemist Ho Kung, who wrote in what he called Chou-hou pei-tsi fag (Prescriptions for emergencies), “Recently there have been persons suffering from epidemic sores which attack the head, face and trunk. In a short time these sores spread all over the body. They have the appearance of hot boils containing some white matter. While some of these pustules are drying up a fresh crop appears.” The most widespread description of the disease, which influenced clinical care into the seventeenth century, comes from the tenth century, when Rhazes, a Persian doctor based in Baghdad, wrote A Treatise on the Small-Pox and Measles. Evidence from China, India, and many parts of Africa demonstrates that smallpox has been a constant companion for centuries. Throughout much of northern India, especially in the eighteenth and nineteenth centuries, smallpox was considered a divine presence, not a disease. Sitala was the goddess of smallpox. The Cherokee, by the 1830s and perhaps sooner, had developed a

31 Pandemics in the Florentine Codex makesin theFlorentine Codex clearit wassmallpox that had butadescription from1520 seenbefore, hadnever disease they calling itaplague oradistemper. Mexica The hadnowordfora calleditbynameratherin muchofEurope—that they thansimply centuriessmallpox wasacommonchildhooddisease seventeenth thesixteenthand observers—by contemporary symptoms tomost based solelyonacolonial-era description.Soclear wereits pneumoniaandtuberculosis between distinguishing for example, described byHo identifying itisless complicated Chung, than, of smallpox’s first notablythepustules uniquesymptoms,most be maddeninglyvague intheirdescriptions.However, because with symptomslike fever, malaise,oracough.Eyewitnesses could of theAmericasischallenging.Many soundsimilar, presenting Identifying thediseasespresentamongindigenous population morphed intoacenturies-longpandemic. caused abarrageepidemicsacrossthehemispherethat oflethal smallpox continuously foundareadysupplyofsusceptiblehosts, century,early sixteenth tothemiddleofnineteenth asit indigenous population byasmuch 90percent.From the to theNew World, whereitandotherdiseasesreducedthe AfricanslaveThe trade andsettler colonialismbroughtsmallpox affected. placeinthepsyches ofthoseit would have apowerful occupied the living.It isnosurprisethat adisease that wreaked suchhavoc whospreadthediseaseamong realms, turningpeopleintoghosts andheavenly theearthly between transcended theboundary Inevent. Japan, theAinu consideredsmallpox agod that longer anatural, oflifebutafearedandterrifying normalpart diedinthebushunattended.dead; theinfected Death wasno smallpox epidemicinthe1770s. their No bury longer wouldthey amassive ritesafter Africa, theXhosaabandonedtheirfunerary Africa, theYoruba andothershadasmallpox deity. In southern Kosvkvskini intheformofsmallpox. In thoughttomanifest West spiritcalled dance calleditohvnvdesignedtoappeaseanevil 32 Smallpox 33 There came amongst us a great sickness, a general plague. It raged raged plague. It There sickness, a general amongst came us a great all over many covered amongst It numbers of people. us, killing vast on the chest, the face, on the head, with sores: on everywhere. It nor nor turn his head, himself, could move was devastating. Nobody the victims so terrible that The sores were partflex any body. of his nor on their backs, nor move from one side could not lie face down, they And when they cried move even tried to a little, to the other. others died of the disease, and many died Many out in agony. They starved because there was no one to death merely of hunger. they were had their faces ravaged; left them. Many alive to care for for life. Others lost their sight, they they pockmarked, were pitted became blind. The worst phase of this pestilence lasted 60 days, of horror. 60 days How did a disease like smallpox, which was not especially virulent which was not especially smallpox, did a disease like How such a killer become seventeenthin Europe until the late century, England thought Godin the Americas? Colonists in early New as both a punishment and disease to Indians had brought death to clear the land. The and a mechanism ways for their heathen reflectingPilgrim chronicler William Bradford, on a 1633 pleased God epidemic, wrote, “It smallpox these Indians to visit As a result, “God hereby cleared our hath sickness.” with a great reported Thomas Virginia, Roanoke, Hariot In title to this place.” “it was the work of God thought that through the Algonquian that whom we we by him might kill and slay our means, and that blamed the French. The Huron would without weapons.” missionary of a massive writing in the wake According to a Jesuit considered the Huron 1630s, the epidemic in the late smallpox because everywhere sorcerers on earth,” to be the “greatest French died and missionaries lived. went, Hurons the Jesuits There no mistaking is usually for something smallpox else (though from measles can be challenging). it separating decimated the Aztec capital Tenochtitlán and allowed for the for the and allowed Tenochtitlán Aztec capital the decimated takeover: Spanish Pandemics protective antibodies; motherscouldnotcare forsickchildren protective Pregnant beensickcouldnotpasson womenwho hadnever of non-immunes remainedinacommunity, smallpox thrived. century.)decades ofthetwentieth longasasufficient number As smallpox amongthepastoral populations ofKenya intheearly of effects thedevastating same phenomenonhelpstoexplain immunity.endemic, providingthemnochance toacquire (This populations werenotlarge enoughforsmallpox tobecome epidemicweredead.Many fromtheprevious survivors meant that inmany epidemicarrived,immune placeswhenanew into theNew World, epidemics, combinedwithatimelagbetween and perhapsmorevirulent.Smallpox’s continuousreintroduction much New World smallpox wasofAfrican,notEuropean,origin themsusceptible.It ispossible,too,thatmillennia ofisolation left the possibility that AmericanIndian homogeneity genetic after smallpox’s helptoexplain Other factors is path. There destructive encountered. not previously theinitialsusceptibilityshould beusedonlytoexplain todiseases American Indian susceptibility todiseaseslike smallpox. Butit catastrophic for results.Virginsoilisanappealingexplanation epidemics—itcouldhavewhen therehadbeendecadesbetween andmuchofIcelandin theearlyeighteenthcentury; at atime non-immunes—initially, intheNew World; everyone theKhoisan smallpox arrivedinapopulation that hadalarge numberof population. Alltheconcepttellsusisthat whenadiseaselike 1707 and1709, anepidemickillednearlyathirdofthis“virgin” inIceland,South Africainavirginsoilepidemic1713; between withagivendisease.Smallpox are afflicted ravaged Khoisanof the or stronger. is not so. All populations That are virgin soil until they andracegenetics combinetocreate populations that areweaker thenotionthat Virginsoilcanperpetuate somehow exposure. peoplewithnoprevious amongst became apopulation leveler for many yearshadbeenacommonchildhoodailmentinEurope conceptissimple:adiseasethat called virginsoilepidemics.The ascribecatastrophicHistorians population losstowhat often are 34 Smallpox 35 Smallpox rearranged the ethnic North landscape of native rearranged Smallpox century more than a beginning in the 1630s, America. For pelts, in beaver trade spread by the European/native smallpox, Lakes and the in the Great guns, and alcohol, wrought changes in the 1630s, the borderlands. Devastated by smallpox plains/prairie capture of enemies increased their “mourning wars”—the Iroquois foe, the Huron. dead—against their longtime to replace Iroquois the Huron. it nearly decimated the Iroquois; ravaged Smallpox military prowess, allowed the And this, combined with Iroquois The same epidemic as the dominant power. to emerge Iroquois further to seek refuge west among other forced the Sauk and Fox of newgroups, fostering the creation ethnic identities. Smallpox the ethnic coming and coming, rearranging and order again kept again. Differential mortality left some groups weak and others powerfulstrong. middlemen The Anishinaabe-speaking Monsoni, 1670s, were nearly wiped out by by the trade in the beaver survivors drifted groups, and by to other in the 1730s; smallpox The left to die of by so much death disruption caused many of wrote William Bradford the 1630s, In and dehydration. hunger the survivors “the condition of this that epidemic of a smallpox of this and theypeople was so lamentable fell down so generally nor disease as they end not able to help one another, were in the to to drink, nor any water to fetch a fire nor not to make a little product epidemics were a Smallpox of other bury the dead.” calamitous developments The Southeastern of colonization. Great possible only by the was made of 1696–1700 Epidemic Smallpox slave disruption and constant native movement brought on by the communities via native for decades disrupted that trade trade—a and migration. raiding when they themselves became sick. Many Indian communities communities Indian theywhen sick. Many became themselves often groups large a single shared further, densely populated; were dwelling—perfect smallpox. spread of rapid for the conditions Flight was the well visited the sick. idea of contagion, Without any spread. common; smallpox Pandemics same epidemic moved west, leveling the Blackfeet, theGros theBlackfeet, leveling same epidemicmoved west, suffered anepidemic that nearly finished themoffin1837–38; the century. Mandan, The Hidatsa, andArikara ontheMissouri River Smallpox continuedtotormentIndians intothenineteenth war, andkilledagreat maney, moveduptheMissourie.” andthey werereducedtheSiouxand otherIndians they them after waged wasaffrd.[afraid] of ones, all[the]nationsthis maladey before the nation andreduced themtoonelarge Village andSomeSmall the Missourie of thegreater lowdown,theSmallpox destroyed part November 1804,“Maney Villages livedinSeveral on yearsago they visitedtheplainsin noted whenheandMeriwether Lewis Missouri The Rivervillages William Clark hadbeendecimated. As Great Plainsregion wasdominated byhorse-mountedhunters. pandemic throughtheblessingofgeography. By1800,theentire plains—particularly ofthe Sioux,sparedtheworst thewestern peoplesof balanceofpowertipped towardtheequestrian The familiesonly,A few fromeachofthevillages, escaped.” by smallpox, whichbroke outamongthemat differenttimes. populous villages, nowdepopulated entirelydestroyed andalmost large; itcountedthirty-twotimes theRicara nation wasvery 1795, theFrench trader Jean-Baptiste Truteau wrote:“In ancient the Missouri River. Arikara fellbyasmuch80percent.In The plains,thepandemicnearlywipedoutvillages along northern West century. fromtheeighteenthtomid-nineteenth Onthe andlargest, Indian powerful, the most peopleintheAmerican Among otherreasons,avoiding smallpox allowedthemtobecome stayed putandwaitedfortradecenters, they tocomethem. avoided smallpox: rather thantravel tosmallpox-ridden trade the southernplains,onceshocksubsided,Comanche reaching alltheway toHudson Bay andthePacific On Northwest. In theearly1780s, outofMexico apandemicsweptnorth City, Ojibwa. peoplelikevoid stepped thenorthern people.Into ceasedtobeadiscrete they the the endofcentury 36 Smallpox 37 Inoculation, and later vaccination, began to change that. that. to change began vaccination, and later Inoculation, introducing a small amount of the disease involved Inoculation into a cut a low-level to induce reaction. If all went well, the would experience and would patient a mild form of smallpox who had caught disease become immune for life, just as anyone and survived. had been practiced in parts Inoculation of Africa, and China long before it became common in Europe in the India, of its effects News trickled into middle of the eighteenth century. the beginning of the century—in at States England and the United reported one of his slaves that Mather Boston, Reverend Cotton it was common; news Africa had told him that of from West In early modern Europe smallpox was a familiar foe, endemic in was a familiar Europe smallpox early modern In pandemics in others. places, flowering into epidemics and many was not an smallpox Before the middle of the seventeenth century, was a low-level It disease rarely endemic especially virulent killer. texts in medical as dangerous about or the accounts of written Therewere no major epidemics. In chroniclers and travelers. late-sixteenth-centuryplaces like London, few died of the disease, changed. smallpox and those few were children. Then, somehow, major By the eighteenth century it had become the continent’s and imagination surpassing the plague in the public killer, recurring Beginning in 1649, and intervals regular at for mortality. responsible for epidemics became smallpox the rest century, of the in London.more than 8 percent of annual deaths By the middle of 1762 smallpox the eighteenth century figure had doubled: in that percent of for 17 claimed 3,500 people and was responsible By the end of the century claimed smallpox mortality. London’s between 8 and 20 percent of the population. Ventre, and the Assiniboine. and the the void was to fill the Coming Ventre, powerfulincreasingly Lakota, of the alliance Cheyenne, and AsArapaho. the expanding further moved people American and world they the Indian further west in the mid-nineteenth century, the Lakota, by the Comanche, the dominated found, a world Cheyenne, and the Arapaho, by smallpox. created was a world Pandemics attenuated cowpox wasquicklyacceptedassuperior toinoculation smallpox anddemonstrating immunity. Vaccination with proving that apatient itworked with bysubsequentlyinfecting him,Jenner’s withcowpox before had inoculated innovation was to theworld.Whileothers years later heannouncedhisdiscovery called cowpox variolaevaccinae,orsmallpox ofthecow.) Two term“vaccine” comesfromJenner,beginning oftheend.(The who rather thanhumansmallpox viavariolation, itsignaledthe himwithasmallamountofcowpox, English boybyinoculating In 1796, whenEdwardJenner smallpox inayoung prevented vaccination. history: breakthroughsinmedical way important foroneofthemost Thissmoothedthe had aspecific,efficacioustooltofightitwith. changed theway peoplesaw smallpox: itbecameadiseasethat continuedtosufferfromsmallpox. towns; they Inoculation thansmallrural weremuchharder toinoculate like London halfofthe eighteenthcentury.public healthoverthelast Bigcities on towns rather individuals,hadanincreasingeffect thanjust ofentirevillages and combinedwith the inoculation in method, EuropeandtheAmericas.Improvementsacross muchofwestern ithadbecomefirmlyestablished to thedisease.Bymid-century savedinoculation livesbyincreasingthenumberofthoseimmune withfate. withfiercerebuttal: Mostinterfered met objections thatsmallpox wasdangerous, it andconcerninreligiousquarters peoplewith that infecting worry wasopposition,however: There British medicalpractice. soonfollowed,anditbecameacommonfeature of inoculations Royal personinBritaintobeinoculated. son wasthefirst waswell-known;in1721 wherethepractice Constantinople, her ambassador toTurkey, in in1718 hadherdaughterinoculated Mary Wortley Lady after Montague, thewifeofBritish begantospread.It caughtoninthe1720s century seventeenth peasants fromPoland inthe andDenmarkwereinoculating arrivedinEngland1700; fromChina inoculation andwordthat 38 Smallpox 39 In Japan, vaccination initially received a skeptical, even a skeptical, initially received hostile, vaccination Japan, In Those reception from a country was previously that “closed.” who imported to the country vaccine of were in the vanguard conduit for was a principle vaccine to the West; opening Japan The had been accepted. vaccine By the 1850s modernity. to use a state-sponsored attempted Shogunate Tokugawa and the Ainu less “primitive” campaign to help make vaccination Whether project that was entirely successful is more Japanese. Ainu beliefs long-held is clear is that But what debatable. regarding curing in the be maintained no longer could smallpox A whole belief systemface of vaccine. was rendered ineffective in In Europe, despite the face of this new and effective procedure. the practicesome early opposition from those who thought dirty or doubted the existence of a single disease organism able to be as it became spread, especially vaccination stopped by another, Sweden there were twelve compulsory in some places. In 1822 there were eleven. in 1800. In deaths thousand smallpox with smallpox: there was no risk of catching smallpox, which which smallpox, risk of catching was no there with smallpox: of Jenner’s three years it. Within spreading no risk of meant been had in England thousand people hundred a announcement decades: two over the next more followed two Millions vaccinated. 1800 By in France. nearly the same number and million in Russia the following year it America; in North had arrived vaccination mid- By it went to India. and from there arrived in Baghdad, American Indians. dwindled among ravages smallpox’s century, before it with smallpox) (and variolation with cowpox Vaccination Bay toll. By the 1830s, the Hudson’s helped reduce the death portions population good of the native had vaccinated Company doctors colonial of western Canada; in Guatemala began to medical even adopting Mayan in the 1770s, inoculate the Maya States, the United In the use of obsidian knives. techniques like too generally were Indians efforts American vaccination among Even on the Missouri. the horrible epidemic late—hence too little, the disease and people acquiredso, as more and more immunity declined. toll the death less frequently, was introduced less and Pandemics had a profound effect onthepublic’shealth andhadaprofound effect health.Reducing thatanindividual’s targeted It isanintervention achievement. Vaccination smallpox wasamonumentalpublichealth against complications thanwereperishingfromsmallpox. children weredying—sixtoeight peryear—fromvaccine-related itwasbecausemore abandoning routinevaccination in1971, world. WhentheUS Public Healthrecommended Service Europe, theUnited States, ofthedeveloped andmuchofthe rest smallpox ceasedtobeamajorproblemin century mid-twentieth that bythe minor—which islesscontagiousandsevere—meant as wellthegradual replacementofvariola majorbyvariola majorappearancethe last ofsmallpox onthecontinent.Vaccination, appearance oflocal outbreaks,the1870–75 Europeanpandemicwas regarding vaccinationDespite complacency andtheregular in1898and 1907.were overturned vaccination. Various provisionsoftheVaccination of1885 Acts vociferous andat timesviolentoppositiontocompulsory ledto and asensethat smallpox haddiminishedinimportance forstate intrusionintoEnglishbodies distaste with apowerful the causeofdiseases—environment, contagion,miasma—along vaccination laws.compulsory In England,however, debate over of Europeoutitsslumber. passed EnglandandGermany estimated fivehundredthousandpeopleandsnapped much 1870–75—sparked bytheFranco-Prussian War—killed an pandemicof thousanddiedfromsmallpoxthirty inEngland.The not necessarilyconferlifelongimmunity. 1836and1839 Between itinitially, thoughnooneknew so diditseffects: vaccination did theinitial zealworeoff,reduced smallpox tosuchlowlevels, and occasions,foroncevaccination eruptedonseveral still had Despite theearlysuccessofvaccination, majorsmallpox epidemics declined. European population fromsmallpox climbedasmortality The 40 Smallpox 41 Alone among infectious was an ideal candidate diseases, smallpox had been developed A freeze-dried vaccine in the for eradication. in of deploying vaccine the challenge 1940s, which meant that late had been theoreticallytropical climates surmounted. The telltale and surveillance, methods made it easy to spot. Isolation rash Eradication Smallpox pioneered in the early 1970s by the WHO’s animal reservoir to stem its spread. No (SEP), worked Program malaria, carried by mosquitoes, there was no existed. Unlike the obviating vector eradication, to consider when contemplating The manipulation. push for environmental need for large-scale support, international garnered widespread allowing eradication its efforts—beforethe WHO to intensify the newly ramped-up existed, more or eradication campaign began in 1967 smallpox Smallpox is the only human infectious disease humans have the only human infectious is Smallpox disease humans have The was in Bangladesh major lasteradicated. case of variola its last minor made appearance, variola years later two in 1975; a decade after more than embarking on in Somalia. A little the campaign in 1967—something an intensified eradication been reluctant had initially Organization to do, Health World instead deciding to try malaria and failing—the to eradicate WHO declared the planet in 1980. By almost smallpox-free measure—the cost; the logistical,any political, and social and the humanitarian effects—itchallenges; was a colossal accomplishment. the number of susceptible people in a population to a number to a population people in a of susceptible the number allow an infectious to insufficient spread is the disease to key to health, the public’s toward geared measures it. Earlier controlling of plague, were very during times of quarantine the use like aimed to the disease stop the spread of Quarantine different. during a particular the possibility reduced epidemic; vaccination would occur an epidemic that the first in Once enough place. host, with no non-human smallpox, been vaccinated, people had had no place to go. Pandemics by all as essential; frequent international meetings helpedto by allasessential; frequentinternational meetings campaign involved countlesslocalpeoplewhose inputwasseen The the workoftop-down planningemanating fromGeneva. SEPwasasuccess.Butitshouldnotberememberedas The was smallpox-free. campaign inIndia especiallychallenging. Still,by1975 India and thequality ofvaccine—all thesethings andmoremadethe local officialsandthe Indian government;problemswithsupplies Indianbetween authoritiesandtheWHO, aswellbetween alliance withIndira Gandhi’s authoritarianregime;friction progress. Coercionandintimidation bythecampaign’s fostered SEP maderapid, thoughnotnecessarilysmoothorconflict-free, where theWHOlauncheditslargest campaign.Even therethe intransigentEthiopia. Smallpox wasmost in India, andthat is smallpox shrunktofour—India, Bangladesh,Pakistan, and yearsthenumberofcountrieswithendemic rapid. Withinafew Once theWHOlaunchedintensifiedcampaign,progresswas people peryear. smallpox claimedtwo ofAfricaandSouthAsia, million parts majority mortality, Still,whereitcausedthemost ofthecosts. in where thecampaigntookplacethat wereresponsibleforthe billion intoday’s dollarsontheSEP. Butitwasthecountries The enormous financialburden. United States alonespent$1 frommoreserioushealthmatters,distraction aswellbeingan America,eradicationof Latin seemedtosomeanunnecessary presentbutnotasignificantconcern,likewhere itwasstill much the conditionsthat gave place. risetodiseasesinthefirst In places places. Intensifying on onsmallpox lessenedthefocus thefocus pressinghealthprobleminmanycountries, itwasnotthemost ofJenner’sintroduction vaccine. presentinsome Whilestill But why eradication? Smallpox hadbeendecliningsincethe at theWHO.afterthought less, innameonly;itwasapoorlyfundedandinadequately staffed 42 Smallpox 43 Indian children support the WHO and Indian government’s government’s support children the WHO and Indian Indian Smallpox Eradication Program in the 1950s. Public acceptance in the 1950s. Public of the Program Eradication Smallpox effort was critical to its success. 3. Pandemics world ofthisoncevirulent,muchfearedkiller. remindedthe briefly forgotten discovery therefordecades.This found inanunusedNational Institutes ofHealth storage room, Union. ButinJune 2014, two vialsofviablesmallpox DNA were during theColdWar bytheUnited States andtheformerSoviet away labs, secreted solelyinsecured Live smallpox nowexists talesdonooneanySimplistic good. localconditions. complex that wasresponsivetooften effort international, andindigenouscampaign reallywas:amultilevel, maskingwhatwould provideafalselessonfromthepast, the toallthoseinvolved. It work oftheWHOwouldbeadisservice heroic individualsmarshalingtheirtroopsorthe ofafew efforts think ofthesmallpox campaignas successful solelybecauseofthe ways inwhichsmallpox wasandnotbeingcontrolled.To encourage collaboration, shareideas,andlearnfromthemyriad 44 Chapter 3 Malaria

Malaria originated in Africa and is caused by an infection with a parasitic protozoan of the genus Plasmodium. Throughout most of history, four types have infected humans: falciparum, malariae, ovale, and vivax. Recently, in Southeast Asia, as humans come into more and more frequent contact with primates due to deforestation, P. knowlesi has been causing malaria at an accelerating pace. The most common kinds are P. falciparum and P. vivax. P. falciparum is more lethal and dangerous. It is responsible for the vast majority of global malaria deaths.

Malaria might have existed in our hominid ancestors five million years ago. But because of the complicated lifecycle of the parasite, for an epidemic to occur a number of conditions must be met that provide the environment in which a sufficient number of mosquitoes and their human hosts can meet. Because it so often kills its host and does not live long in the human body—unlike tuberculosis, which can remain dormant for a lifetime after infection—malaria needs a constant resupply of hosts. This requires a dense population, which emerged slowly when the forests of central Africa began to be cleared for agriculture four to ten thousand years ago. Lots of mosquitoes are required. And mosquitoes need particular living conditions: those made available when farmers cut down vegetation and cleared the absorbent soil, creating pools of water ripe for mosquito breeding.

45 Pandemics bce millennium thefirst appearsinmuchoftheworldafter evidence Knowledge ofmalaria’s Africaisscant.Solid earlyspreadbeyond is immunologicallynaive. To onethat population meet must spread,amalaria-experienced humansfortheirbloodmeal. toprefer Anopheles gambiaeevolved available livestock With few mosquitospecieslike ashosts, farmers provided susceptiblehumanhosts. and malaria.Malarianew peasant steady influxof flourished asa formosquitos and creating marshesinothers—conditions perfect Fenlands Englandthisledtodraining ofsoutheastern someareas production. increased urbanization intensifiedagricultural In the England,where agrowingpopulation and seventeenth-century One canseethispatternagriculture. insixteenth-and arerelated: thegrowthofcitiesfueledin production ofurbancentersandagricultural expansion The and agricultural. conditions that smoothed theway formalariawerelargely rural of theenvironment. Urban conditionsgave risetoTB;those To needshumanmanipulation thrive,malaria,like tuberculosis, tropical Africamadeitsway intotheNew World tropics. centuries, whentheslave trade wasat itsheight,that malariafrom century.nineteenth andeighteenth It wasduringtheseventeenth untilthemiddleof slave trade century fromthelate fifteenth duringtheera Its oftheAtlantic reachexpanded development. Malaria spreadacrossearlymodernEuropealongsideagricultural malaria’s Europeanstronghold. century,then untilthemiddleoftwentieth southernItaly was remains ofaoncevibrant drainage addedtothemix.From system marshy, andthecrumbling Deforestation malarial wetlands. water andweretransformedwhich then accumulated into conditions forcedpeasantstoabandonlow-lyingfarmlands, malarious intheera ofthelate republicwheneconomic environmental regionaroundRomebecame change. The as malaria followed agriculture andhuman-induced asmalariafollowedagriculture 46 Malaria 47 Following in the wake of agricultural settlement and the of agricultural settlement in the wake Following from the havoc malaria wreaked introduction of slavery, valley to the Caribbean and Chesapeake to the Mississippi beyond to South America. Exactly when malaria first arrived brought malaria is unknown—perhaps early English settlers By the vivax) to the Chesapeake from southern England. (P. middle of the seventeenth century had introduced slaves African Agricultural and rural development have been generally been generally Agricultural development and rural have malaria, but poor urban of responsible for the proliferation malaria can make of stagnant and the presence water sanitation an urban disease—something happening more and more is that global south. Other human-created in the megacities of the Zone Canal in the Panama also foster malaria. In environments the mosquito most responsible for the early twentieth century, thrived in the conditions spreading malaria—A. albimanus— construction. the entomologist An noted at by the canal’s created with man and time: “Anopheles albimanus is closely associated and surroundings about his habitations finds its most congenial in the course of agricultural,in conditions he creates engineering Orenstein, authors LePrince and A. J. Joseph and other work.” malaria (1916) noted that Control in Panama of Mosquito “develops and when the soil is disturbed most by large rapidly and fills accompanied by the introduction extensive excavations their work.” of non-immune labor housed near the site of Not all agricultural production is the same. Generally, where where agricultural all productionNot same. Generally, is the agriculture capitalized intensively north the global took off—in of parts and States western of Europe—agricultural the United this meant ever England, more followed. In improvement as out-migration as well methodssophisticated water, for draining the number to cities, which reduced population of the rural the less it. In of transmitting to malaria and capable susceptible developed south, agricultural global as improvement was not conditions persisted;widespread; malarious and a susceptible remained. population Pandemics East andWestEast Indian climates. ofEuropeansbecomesseasonedtothe of time,theconstitution Europeans inHot Climates(1786), James Lindwrote,“Bylength AnEssayontheDiseasesIncidentalto onthesubject, text solve.” Somearguedthat Europeanswouldadapt.In hisclassic attemptednumbers, isaproblemwhichnopersonhashitherto to unhealthyseasons, andmost situations, whilewhitesdieingreat reasonwhy Negroes escapetheir fury,Colonies, “The intheworst Practical Rules fortheManagement ofNegro SlavesintheSugar in1811his Collinswroteofmalariaandyellowfever Robert Dr. them.It As continued toresist wasaconfoundingquestion. were fated todie from tropicaldiseaseswhileAfricanslaves Noting differentmortality rates, many wonderedifEuropeans becametangledupwithraceof thesequestions andslavery. ofplaceorifittraveled.wondered ifdiseasewasaproduct Many earlier, physicians inthetropicseighteenthcentury Just andplague aswithcholera century later inthenineteenth epidemiological zoneoftropicalAfricatotheNew World. unfreelaborintotheAmericas;itbrought only imported indentured Europeansasasourceoflabor. slave The trade not seemed that enslaved replaced Africanswerelesssusceptible,they acrosstheNew Worldtheir indenturedservants tropics.Whenit P. falciparum.It thrivedamongthenon-immunesettlers and settling the tropics was replaced by a set ofrigidideasabout settling thetropicswasreplacedbyaset peoples,andEuropeanoptimism about between boundary would adaptbegantodisappear. Racebecameafixedandhard change; theideathat health andthat climate one determined century,Beginning inthenineteenth ideasaboutrace beganto many thoughttheanswerwasyes. eighteenth century In biology? livedamong?Didclimate the determine diseases they universal humanrace, equallyadaptabletotheclimates and those whoresideat home.” Didthismeantheremight be a diseasesabroad,as habituated, aregenerally toasfew subject . 48 . . Europeans, whenthus Malaria 49 For much of the nineteenth century, malaria, along with cholera, malaria, along with cholera, of the nineteenth much century, For disease, brought on by the gases was the quintessential miasmatic remains of vegetable and animal waste; rain from rotting emitted or other disturbances of the soil such as agricultural urban or development could contribute to the onset of these gaseous Germ theory changed name evenemissions. Its bad air. means detected Afterthat. Alphonse Laveran in the malaria parasite in the technologyhuman blood in 1880 and continuing advances of pathology see, and allowed more and more people to literally malaria was caused by a protozoan, miasma thus accept, that the end Near theory vector. came the prevailed. Next no longer Grassi and Giovanni in 1898, Ronald Ross in India of the century, malaria. transmitted anopheline mosquitoes proved that in Italy After in the seventeenth in the tropics appearance its initial was pushed ever malaria via the varying inland of forces century, an agriculturalStates, and United the In human migration. moved westmalaria frontier Mississippi into the Ohio and mining drew gold into the labor and malaria Brazil, valleys. In for way forest soon followed to make clearing hinterlands. Massive farms needed to feed the newthe vast labor force—more than one during the so-called came to the interior million African slaves This the created newmining century environment of the 1700s. most vectors, efficient falciparum’s perfect for one of P. habitat Anopheles darling; the sedentary provided the population mining perfect exploded. But while malaria remained a hosts. Malaria problem into the twentieth centuryAmerican South, the in the itself: England repeated established like in places pattern improvements in agriculture of tended to reduce the burden housing and nutrition with them better malaria, as these brought alongside decreased exposure. But in the tropics, malaria part region. worsened and became a “natural” of the tropical places and “tropical races.” In this way, malaria in the in the malaria this way, In races.” “tropical places and tropical of medicine. to the racialization contributed tropics Pandemics the way. Accordingtotropicalmedicine’s founder, Patrick Malaria parasites tounderstanding andtheirvectors. devoted led medicine— fieldofmedicalinquiry—tropical anew fostered discoveriesthat ledtothepossibilityThe ofcontrollingmalaria white race. that thetropicswereunsuitedto century nineteenth that throughout muchofthe the conviction hadprevailed of theseregionsbytheCaucasian.” Optimism like thisoverturned settlement pointoftheeffective starting tropics andastheeffective demonstration “earliest that thewhitemancanflourishin considered theworkheandothershaddoneinPanama asthe 1909 inJournal oftheAmericanMedical Association,Gorgas oftheTropics Conquest “The fortheWhiteRace,” publishedin towardthecivilizedsettlementan essentialstep ofthetropics.In Gorgas’s successinPanama wasapublichealthtriumphlaudedas immunity). succumbed. Butmalariaeventually yellowfever,malaria (surviving bycontrast, grants lifelong wasgreater,infection with becauseitispossibletobereinfected disappeared.Malaria of yellow fever tooklonger—the reservoir of theUnited States madethisallpossible.Withintwo years abundantresources them.The of mosquitoesandthendestroying thebreedinghabitsandlocales himselftounderstanding devoting attacked withunprecedentedzealby malariaandyellowfever charge oftheUnitedZone healthy, torenderthe States’ effort century,turn ofthetwentieth thecolonelin WilliamGorgas, problem ofmalariawaslimited.In thePanama at the CanalZone relentlessly attacked withsufficientresourcesorwherethe Vector controlworked—in placeswheremosquitoeswere social oreconomicconditionsthat gave risetomalaria,prevailed. andparasite control,ratherresult: vector thanmitigating the mosquito.The byonething—thebiteofaninfected explained bymanywent fromadiseaseexplained thingstoadisease Malaria, after, like cholera itandplagueshortly andTBbefore 50

Malaria in tropical in tropical . . . 51 Manson, it was “by far the most it was “by important disease Manson, Malaria declined where agricultural improvements reduced Malaria of life meant exposure to quality and improved mosquito habitat parts But in many malaria was less frequent. of the world peasant opportunity and to escape malaria little farmers had, and have, farming undercapitalized Peasant-based, it. catch to chances many left people poor and continuously exposed. Large-scale many agriculture,plantation focused on a single crop and employing the often the conditions for the spread of malaria: created poor, rural the destruction perfect of forests created for farms breeding demanded lots of plantations grounds for mosquitoes. Since large market locally—a in rural available labor—labor not always of the as the forced labor migration migratory Just labor emerged. tropics, World brought malaria to the New trade Atlantic slave in parts of Africa, South America, and Asialabor migration in the nineteenth and twentieth centuries introduced the disease into recruited from areas with once malaria-free zones when workers no malaria returned home and brought the disease with them. It irrigation was “the opening of the tropics” to large-scale, supported agriculture, according to C. A. Bentley and S. R. in the Duars Christophers in their The Causes of Blackwater Fever turned malaria into an epidemic disease in India (1908), that irrigation poorly, beginning in the 1860s. Where the soil drained pathology,” because it was “the principal cause of morbidity and morbidity cause of principal it was “the because pathology,” This newfield spawned mortality and sub-tropics.” the tropics in Schools of agenda. and a research journals, programs, training Medicine School of Tropical Liverpool tropical medicine—the Europe and founded across was first, opening in 1897—were hubris brought mix of optimism and A potent States. the United on by the very and the in malaria control real breakthroughs could be fought through modern diseases growing sense that Malaria of tropical medicine. medicine fueled the creation places the disease was only for in many control was urgent, of uneven continued in the wake worse as epidemics getting development. Pandemics favoringstrategies: ordealing different killingthemosquito vector whowished tocontrolmalariaweresplit intotwo camps Those tropical world,asolutionwasnecessary. acrossmuchofthe conditions showingnosignsofstopping broughtmalariawiththem.With thespreadofsimilar them, they peoplewhohaddisplaced upbythevery work onplantations set migratedpopulation. Andwhenthey backtothehighlands malarial high veldintothemalariouslowcreated anew forced migration ofblackSouthAfricansfromthemalaria-free conditions causedtheepidemic.In the1920sand1930s,likewise, that wasforcedto migrate becauseofsocialandeconomic arrival ofA.gambiaecombinedwithasusceptiblepopulationThe abandon it.” depopulated because thosewhodidnotdieat oncewould the region. is farfromadequate in todescribethedesolation whichexisted that the“humanlanguagebut likely reported more.Anewspaper death tollwasimmense:officiallyfivethousand, epidemic. The moremalaria,andsparkedthe Amazonwithstill amajormalaria alongsidemigrants from totheSertão, epidemicreturned coastal byshipfromWestimported the whosurvived Africa.Those brought onbytherecentlyintroducedA.gambiae—accidentally confrontedavirulent strain ofmalaria they work. Atthecoast 1936, forcinggreater andgreater numbersofmentofleefind back home,andsparked droughtbeganin outbreaks.Anextended malaria,broughtit contracted they the Amazonforwork.There malaria-free—migrated region—mostly andto tothecoast Sertão poorbysharecropping,thepeasantsof Brazil’sand left semi-arid many timesandinmany places.For plaguedbydrought example, migrationLabor hasbeenresponsibleformalariaepidemicsat scenarioforspreadingepidemicmalaria. the perfect large teaestates attracted anenormousmigrant labor force.It was formalariabreeding;the poolsperfect canals becamestagnant . . . The general wasthat wouldbe The belief theNortheast 52 Malaria 53 After stunning success in several places, vector control prevailed. were other but there pioneer, been the Gorgas have might examples of successful vector control, such as the form known as which targeted Anopheles breeding specific species sanitation, and then in Malaya Watson grounds. Pioneered by Malcolm in the years just N. R. Swellengrebel in Indonesia refined by I, this method of vector control was very War before World Fascist Mussolini’s 1930s, Italy during the 1920s and In effective. Marshes, the Pontine grip by draining malaria’s regime weakened reclaiming them for agriculture, In the area. and resettling of agricultural a smaller program improvement and Palestine vector control brought malaria to its knees. And during the Great Authority Valley the Tennessee States, Depression in the United ridding involved that betterment of rural on a program embarked the region of malaria. Lowering levels water of dam-created eggs, screening doors reservoirs’s A. quadramaculatus to desiccate and windows (a practice widespread since the more and more nineteenth century), applying larvicides to breeding areas, and zones along shorelines to afford mosquitoes grazing cattle creating host all ensured the steadyan alternative decline of malaria in the South. US with the infection from the plasmodium parasite. Gorgas’s success success infectionwith the Gorgas’s parasite. plasmodium from the vector Cuba buoyed and the controlling control, while in Panama of the discovery because made possible was parasite of the Quinine’s prophylactic had virtues quinine. Each and drawbacks. prophylactic as a partly was limited value made up for by its but care of symptoms, to take It worked benefits. therapeutic and were expensiveits on a mass scale; be erratic supplies could it did not stop use. Plus, transmission. taste discouraged awful That is, a person could be infected their with the plasmodium, symptoms stopped still by quinine, but spread the disease. able to was expensive But it and logistically worked. control Vector places were unable to many demanded resources It complicated. addressed the underlying causes of malaria’s marshal. Neither continued presence. Pandemics the WHO decidedto eradicate it.Just asmalaria becamethe So great wasoptimismsurrounding thecontrolofmalariathat asamajordragthat onamodernization willnotact effort.” disease pattern ofanoverlytraditional to adiseasepattern society modernization, orpurposeful istomodify the development, biomedicalgoal ofinternational the modernworld.“The WalshAmerican TBexpert McDermott, toprogressingin thekey delay freedom.” anddestroy Biomedicinewasforsome,like withpoliticalgermspredispose acommunity that toinfection can Paulexpert Russell malariahelped“to putitsuccinctly: remaining poorandmiredintradition—was common.Malaria or becomingmodernandeconomicallywell-developed between that “malariablocks development”—that itmeant thedifference control ofcommunismandthespreaddemocracy. notion The them frombecomingHuk Controlofmalariameantthe terrorists. reclaimedland—andthisisturnkeptsuccessful farmersonnewly landless peasantscouldnowbecome meant that previously ofmalariainthePhilippines teams, andriddingthecountryside Minh–controlledand openingupViet areastoDDTspraying 1956 that malaria controlwaseasingurbanovercrowdinginJava States International Administration declaredin Development United thetideofcommunism.The capitalism andstemming Malaria and controlwastiedtothegoal democracy offostering global healthagenda. formedWHO’s ofthenewly and smallpox astargets postwar controltriumphant.Malariacombined tomake vector joinedTB postwar impulsethat spreadTBcontrolaroundtheworldall DDTduringthewar;andsame ofthepesticide discovery Rockefeller Foundation at eradicating A.gambiaefromBrazil; the malaria;thesuccessofFreddid andnotcarry Soperandthe mosquitoes, especiallyincreasedknowledge aboutwhichspecies ofanopheline theecology Breakthroughs inunderstanding solidified intheyearssurroundingandincluding World War II. Vector control’s placeat thetopofmalariamitigation efforts 54 Malaria 55 The on the MEP was, confidence with which the WHO embarked it turned out, misplaced. Over the fourteen-year lifespan of the practice in than malaria proved far harder to eradicate MEP, theory been. After some early success in suggested it should have was faltering. within a decade the program Venezuela, places like malaria of the world’s majority the vast Despite Africa having projects, other than in a few demonstration did cases, the MEP, Malaria became a natural candidate for eradication. Knowing for eradication. candidate became a natural Malaria and just both mosquito breeding patterns more and more about of the a demonstration malaria, having which species transmitted armed with an agent and being from Brazil, power of eradication designed to kill the insect vector—allthese joined in the of powerful push into the developing postwar world and added on malaria. Also importantup to an unprecedented assault was Malaria the 1955, when the WHO officially announced in that the global health bureaucracy (MEP), Program Eradication The number of experts was is today. was much smaller than it and most were were like-minded; many tiny; comparatively A very on Malaria. Expert Committee members of the WHO’s malaria via indoor residual small group decided to eradicate The were the WHO and donor players major with DDT. spraying such as organizations States; the United like governments largely important supportingUNICEF played roles. Funding as UNICEF; UN agencies and such States came from the United covered the remaining amount—often great local governments at gain. amounted in some cases to little sacrifice for what archetypal tropical disease, it also became the disease that defined archetypal that the disease became it also tropical disease, of the abundant Because overoptimism. and of hubris this era it seemed and DDT, antibiotics especially advances, biomedical diseases. the world of some to think about ridding the time like This infectious in which was the climate disease specialist can look “we Science in 1961 that claimed in Aidan Cockburn T. forward from degree of freedom considerable with confidence to a infectious not too distant a time in the future.” diseases at Pandemics propaganda. (likeposters theonehere), radio campaigns,andotherforms of campaign waswell publicizedthroughcommemorative stamps, 4. All overtheworldduring1950s, theWHO’s malariaeradication 56 Malaria 57 Since the 1960s malaria has made a startling comeback. In some Since the 1960s malaria has made a startling comeback. In in malaria places where there had been significant progress At the there has been a resurgence. and Brazil, India control, like The MEP did have some successes. Malaria disappeared from some successes. Malaria The MEP did have the of Parts 39 percent of the countries enrolled in the program. Caribbean and eastern Europe became malaria-free. Still, in 1969, was not working, the WHO shut it when it was clear the program focus on a single, technological solution to the down. Intense contextmalaria problem while ignoring the sociopolitical the of especially after safety, disease; growing concerns over DDT’s Silent Spring; pesticide and anti-malarial drug Rachel Carson’s resistance; lack of financial commitment—all of these help to explain the failure of the MEP. In other places, like Brazil, the eradicationist impulse clashed eradicationist the Brazil, other places, like In But the of malaria control. with an already working program Health the Pan-American WHO, at global health leadership as the major donor, States, and the United Organization, which and Mexico, Brazil In eradication. remained wedded to success with initial to accept eradication, were more or less forced was met failures: when the MEP pulled the program with later out and mosquitoes (inevitably) returned, they were left with very Then program. and no malaria control acquired immunity little came resistance: first, species had mosquito by 1969 fifty-six developed resistance to DDT; next, mass as a result of careless drug-resistant malaria developedadministration, especially chloroquine resistance. not even attempt to rid it of malaria. The it of malaria. to rid infrastructurenot even too was attempt on the continent eradication great; too and the problem weak the size of the sheer India In one tried. So no be impossible. would MEP staff 150,000, the lack of of more than unwieldy an country, and the growing throughout mostbasic healthcare of the country, DDT resistanceproblem of the conclusion that all added up to was impossible. eradication Pandemics overfishing is imperiling the very food source they relyon. food sourcethey is imperilingthevery overfishing towardoff hunger,instead butin theprocessresultant designed tohelppeoplestave offmalariaisused A technology increaseinfishingishaving stocks. onfish The anadverseeffect fortheirintendedpurpose,millionsarechoosingfood. the nets fishingforfoodandusing Giventhechoice between elsewhere. inNigeria, massive scale,asfishingnets Mozambique, and havein halfAfricasince2000—they alsobeenrepurposed,ona haveWHO claimsthey beenresponsibleforcutting malariarates technology, itskey nets, have worked wellinmany places—the take bed intoaccountlocalconditions.Whileinsecticide-treated work;andithasfailedto coordinated withotherdevelopment werenot wasweak;itsefforts where thehealthinfrastructure has beendrivingtheresurgence incases;itoperated in places ways.MEP insomeimportant It hasnottaken intoaccountwhat eradication, andincludingAfrica,Roll BackMalaria mirrorsthe funding. Yet on malariasurges ahead.Whilenotfocused draw attention tothedisease,andthisledsome increased Global Fund forAIDS,Tuberculosis, andMalaria, hashelpedto Malaria, begunin1998.RollBackMalaria, combinedwiththe controlling thedisease—theWorld Bank–sponsoredRollBack Malaria’s byanother globalapproachto resurgence hasbeenmet malaria (andotherdiseases). inequality andmassivedebt,leaving resourcestocombat fewer growingeconomic fostered of globaleconomicdevelopment theproblem.Patterns exacerbated decrepit healthinfrastructure and anti-malarialdrugs.Increased population movementsanda AIDS, increasingpoverty, ofpesticides andtheerodingefficacy HIV/ developments, agricultural malaria surged becauseofnew been undercontrol,thingsgot worse.In ZambiaandSwaziland contributedtoo.Inresistance, Africa,where malariahadnever unreliablesourcesofDDT,health infrastructures; aswell states monitoringand follow-upin withlessrobust ineffective hadjumped150percent,largely dueto cases; by1965they beginning ofthe1960sIndia hadunderahundredthousand 58 Malaria 59 Finding a technological solution to the malaria problem, whetherFinding a technological solution to the malaria it be bed nets or more effectivehas been the dream of drugs, malaria control since the end of the nineteenth century; it is the tenet the heartcentral of control. The at of the gospel appeal is obvious. And by the middle of the twentiethcentury it seemed all the pieces were in place to achieve seemed the far like what the vector of eliminating via technologyeasier goal instead of help malaria that the conditions or mitigating, eliminating, flourish in the first place. One of the greatest threats to malaria control is resistance. to malaria control While threats One of the greatest resistance been a concern since the advent of anti-malarials has and insecticides, the problem has grown as it has been Now problems held sway. or more immediate downplayed artemisinin, long the most effective anti-malarial, is becoming centuryless and less useful. At the beginning of the twenty-first artemisinin resistance came to Cambodia; in early 2015 drug-resistant falciparum malaria had spread 1,500 miles—via and betweenhuman and vector the border India migration—to If artemisinin-resistant malaria spreads to Africa, the Myanmar. results will be catastrophic. None of these programs focus these programs of rise to give that on the conditions None directs money of its much to Themalaria. Foundation Gates development; also re-enlivened has vaccine foundation the Health World the at 2015, And in May interest in eradication. to eradicating itself all but recommitted the WHO Assembly, single-minded focusmalaria. A however on one disease, much the For consequences. can have wish malaria gone, world would example, malaria in been success in reducing although there has rise, it has recently Zambia where it had been on the places like the expense this success has come at of other been argued that on a single disease like of health interventions.types Focusing focus that from programs on resources away malaria can take health. overall general, Chapter 4 Cholera

Cholera is a horrific disease acquired by ingesting water contaminated with infected fecal matter. Its symptoms—pallid, drawn skin; a gray and ghostlike appearance; rapid and often fatal evacuation of all bodily fluids—are shocking and appear quickly after infection with Vibrio cholerae. For centuries no one knew how to treat it. Then, in the 1960s, medical researchers and clinicians working in Bangladesh determined that a combination of salt, sugar, and water could replace the fluids lost to cholera (and diarrhea generally). Oral rehydration therapy has since saved millions of lives.

Though cholera had been present in India since at least the eighteenth century, the 1817 epidemic, because of its size and severity, is conventionally thought of as the beginning of cholera’s history as a globetrotting pandemic disease. Since then seven cholera pandemics have traveled the globe. The first six were what is called “classical cholera” (V. cholerae O1). Each eventually petered out and cholera retreated to South Asia. For thirty-eight years, between 1923 and 1961, pandemic cholera disappeared. Then, for reasons still unknown, the El Tor biotype—named after its place of discovery in Egypt—began to replace classical cholera, and the ongoing seventh pandemic began.

Cholera, unlike tuberculosis, was not part of daily life; it appeared mysteriously, without warning, from the exotic and increasingly

60 Cholera 61 Fear of outsiders peaked during cholera epidemics. This during cholera 1883 of outsiders peaked Fear cartoon shows an immigrant ship bearing cholera to America’s shores. to America’s cartoon ship bearing cholera shows an immigrant 5. While there are some themes in common—fear, debate over its over debate common—fear, are some themes in While there causes and cures, horror over its symptoms and effects—each pandemic was pandemic has been different. cholera The 1831–32 as far less severe in England than the 1848–49 pandemic—twice reaction to it was the public’s people died in the latter—but many Thefar less panicked. seventh we are in the pandemic—which midst of—has left since has not appeared cholera Europe, where where it had to Haiti, in 2010 But it made its way 1911, unscathed. which did not Africa, than a century. not been seen for more loathed and feared east. Its cause and cure cause feared east. and Its loathed And as unknown. were from and of immigrants poor of the urban a disease it became elsewhere, and and primitivism. filth to symbolize it came India Cholera exposed anxieties, revealed within divisions deep-seated in places economic inequality laid bare social and medicine, and and Hamburg. London, Naples, such as Paris, Pandemics Asian. This opens upthepossibility that This thecholera-likeAsian. exclusively mightnotbe century identified inthe nineteenth that cholera theAsiatic worldwide suggest so confidently instability, anditsability toflourishinmarineenvironments similarity ailments,itsgenomic tomany other gastrointestinal proteannature, itsclinical has made itsoriginslesscertain—its broadly. Researchintocholera’s in recentyears natural history thought theanswerwasIndia—Bengal, Asia more specifically—and Where didcholera comefrom?Beginningintheearly1830s,most delegate tothe1851 International Conferencenoted: Sanitary French itsborderseasilybreachedbythedisease.The connected, symbolizedaglobebecomingsmallerandmore Cholera atthe impuremonster itssource.” wouldsnuffout armofliberty The oftheearth. poison otherparts to wouldtametheplaguethat theirriverisvomitingforth they the Ganges toliveunderfreegovernments hadthe good fortune isreasontothinkthat ifthepeopleofbanks in 1833,“There what seemedtohimbeabarbarianinvasion fromIndia, wrote modern, thefilthy andpremodern.A French writer, to referring thecleanand essentialdifferencesbetween some observers to presenceofcholera inoneplaceandnotanother revealed The suffers frommorecholera thananywhere else. pandemicin1865–71, choleranow until thefourth confront severe cases, impossible. great majority of are,inthevery powerless anduseless,butthey under theseconditions,cordonsandquarantines arenotonly will beforcedtoadmitthat forsuchadisease,sowidespreadand seems tomake ofdifferentpeoplesasoleandlarge family, andyou populations tovisiteachother, that to mix, tomerge, atendency the railways, ofthe andontopofthat thishappytendency numerous andmorerapid; thenavigation bysteamship, Add nowthecommunications thepeoples,today between so 62 Cholera The

.

.

.

63 We have witnessed in our days the birth of a new in our days witnessed pestilence, which have We in the short space of fourteen the fairest years, has desolated Cholera of difference or of an was more than a symbol and dramatic Its presence. interconnected was a physical globe. It into fits of fear; it in Europe in 1831 threwsudden arrival many of a newarrival signaled to some the Some people fled, plague. of just as they Fear had during plague epidemics; others stayed. 1831, times out of proportion was at actualcholera to the In threat. the anxious English awaited through Russia, made its way as cholera pamphlets, Newspapers, its arrival. and rumor spread fear of the editor of the Medico-Chirurgical Johnson, James disease. But Dr. will hardly to The Times: “It Review, cautioned the press in a letter this at rages the terrible malady choleraphobia be doubted that through every British Isles. spot of the moment, epidemically, The association of India with cholera has forever cholera with that stigmatized The of India association this was are not entirely clear—perhaps that reasons For country. had broken cholera been decades since a new it might have strain; 1817, especially virulent in disease became out in India—the called, in physicians Company a pair of East India leading to what “visited diseases” to have 1819, “the most formidable and fatal and between 1817 range, While estimates in modern times.” India most of whom were killed millions of Indians, likely 1831 cholera dwellers. Cholera spread across the rural poor and malnourished Bengal was hit worstentire continent, but of all. Seeing evidence of its destructive across effects as it made its way writer warned in the Britain, a panicked Great toward Russia Quarterly Review: epidemics in Europe before 1817 were in fact cholera—a possibility in fact were possibility cholera—a before in Europe epidemics 1817 shrugged nineteenth off in the century not who could by those origin. Indian but an anything having cholera imagine number of Britons a far greater will frighten to death choleraphobia than the monster itself will ever destroy by his actual presence.” Pandemics transmitted thediseasebut theemanations oflocaleffluvia—the miasma thought quarantine useless; itwasnotpeoplewho in whobelieved suchmeasuresasquarantine. Those supporting combination ofthetwo? To generally beacontagionist meant smallpox andtheplaguetobe? Didmiasmacauseit?Was ita did not.Was itcontagious, asmany bythe1830sbelieved from itequally, many wonderedwhy somegot cholera andothers suffered Sincenoteveryone cholera—were especiallyimportant. toanswerandwhichwerenotlimited century nineteenth ofcholera’sSeveral mysteries—mysteries ofthe ittookmost oftheepidemicwashiddenfromoutsideworld. world—that news the perceptionthat ofthemodern,sanitary Italy wasnotpart onemigration;reduced orhaltedtrade andtourism;restrictions in 1911,theItalian state sofearedthepotentialconsequences— Misguided ornot,fearmatters. Whencholera appearedinNaples making Europemodernwerealsothosethat causedcholera? things rapidly Europe.Might industrializing itbethat thevery ofa horrific livingconditionsintheburgeoning metropolises cripple themodernandprogressiveWest? exposed Cholera a diseasefromtheprimitiveandbackward have East thepowerto theWest’squestion superiority: biologicalandcultural How could ridofthepoorwithcholera. calledinto schemed toget Cholera school anatomy lessons.In France, someworriedthat thewealthy bodiesformedical toharvest poisoning thepoorinaneffort of their angersuspected atcorpse, themobsdirected doctors well asonegrislyandmuchtalked aboutcaseofmurder-for- well-publicizedincidentsofgravethe heelsofseveral robbing,as In Britain,in1832,riotsbroke locales.Comingon outinseveral the plague,takes rootinthesoilithasoncepossessed. life,andthenpassedaway;blasted thecholera, like thesmallpox or natural barrier, people.It hasnot,like thesimoon, conqueredevery variety ofclimate, surmountedevery race. It every hasmastered oftheglobe,andsweptoff fifty MILIONSofour at least portions 64 Cholera 65 The autocratic governments did not take a solely contagionist did not take The governments autocratic approach. They considered local conditions and instituted While debates about cholera’s route of transmission festered—and route of transmission about cholera’s While debates would for decades—something needed to be done in the short this respect it seemed most were contagionists: the from term. In ones such to the autocratic England and France like states liberal the initial response was and Prussia, Austria-Hungary, as Russia, the disease based on historical experienceto treat with the plague revived States and restrictionsand impose quarantine on travel. (sanitary sanitaire the practice of imposing a cordon border) in an out; they careful cholera tabs on the sick and kept to keep attempt the suspected them when possible; they off sick, isolating blocked infected and they zones; disinfected, zealously cleansed, and in and people. As approached Moscow goods cholera fumigated defense—tearing mounted a vigorous the fall of 1830, Russia into and out blocking passage up roads, destroying bridges, The military enforced restrictions on movement; of the city. thousand troops guarded two Sixty disobedience meant death. These severe measures were hundred miles of the eastern border. and resistance. outrage, met with a mixture of indifference, fear, and popular unrest in Moscow sparked hospitalizations Forced angry held mobs freed patients Vytegra, In Saint Petersburg. against their will; they destroyed hospitals. rotting vegetable and animal matter in the soil and the bad air and the in the soil vegetablematter animal and rotting they There produced. strict was no between divide two the a sound theory up with coming a challenge, was Further, theories. for choosing methodological rationale was little because there some facts most and not others; tended to believe whatever suited up: “The summed things A writer in The Lancet their theory. medicine, as an inductiveprogress of is retarded science, by the construction of hypothetical of theories, or the assumption and also and imaginary, principles which are altogether gratuitous from a principles or conclusions, by the deduction of general limited number of facts.” Pandemics help to explain thedisease’shelp toexplain hold on someplacesandpeople. an association andcholera. poverty between Living conditionsmight immorality.sin orbroughton byitsvictims’ Many begantonotice that choleraSome believed wasGod’s punishmentforslothand inagivenlocalegot it. not whollysatisfying either; noteveryone ofthelocalenvironment was itwasaproduct aside.That was cast acontagiousdisease, passedfrompersontoperson, it wasstrictly ofcontrolwerenecessary. andmethods explanations ideathat The withplague provedinadequate; alternative experience historical commenced.Relying onthe reflection the diseasehadretreated, pandemichadwornoffand But oncetheinitialshockoffirst did aboutcholera. thanthey andpopularunrest oftrade restrictions about theeffects authoritiesworriedmore ofinaction; adoptedapolicy in Germany in the1840sand1850sthat placessuchasLübeckandHamburg tocholera whenitcameback degree. Sodifferentwasthereaction inthesame returned feltinthe1830s,never disease, sostrongly the mid-1830s, incontagionism hadwaned.Fear belief ofthe wavethus, bythetimefirst ofcholera in Europewaswaningin haddemonstratedexample, that quarantine didnotwork.And ofthoseplacesthat hadalreadysuffered—Russia,experiences for onthe along trade routes, thecountriesitentereddrew relaxed theirapproach.Additionally, ascholera traveled west wereminimal, mountedthatgovernments their effects as evidence trade andtravel toenforce. becameincreasingly difficult Further, on withthedisease,initialrestrictions gained moreexperience citizens,andpublichealthofficials take states, doctors, place.As to ontradeopposition toquarantinecausedashift anditseffects placed upondailylife,andthemerchantclass’s vehement of transmission, restrictions populardispleasureat thesevere contagious.Growingambivalencejust regardingcholera’s method moreuponthepoor,prey that thediseasemightnotbe suggested that cholera mighthave that itseemedto localcauses,andthefact at mostly thepoor.regarding hygiene—directed possibility The sanitation toothlessadmonitions measures—mostly rudimentary 66 Cholera 67 It was in England where this view was It went furthest in fostering public action. The between a given place and cholera association was most heartily by Edwin (and ill health generally) embraced managing Britain’s Chadwick, 1830s was a bureaucrat who in the between poverty and with the relationship Fascinated Laws. Poor to the utilitarianism of philosopher Jeremy illness and committed Bentham, Chadwick in and teamed up with several physicians 1842 published the Report on the Sanitary Condition of the of Great Britain. Repletewith maps, Labouring Population charts, between the correlation and statistics demonstrating and the sanitary conditions of specific illness, poverty, Report became the bible of the British neighborhoods, Chadwick’s sanitary movement, which reached its apex in 1848 with the Act of the General and the creation Health of the Public passage an unjust economic Villermé thought that Board of Health. starksystem between differences the rich and the poor; created dirty and clean only saw miasmatist, Chadwick, a committed places. There social and economic was no need for large-scale restructuring; needed to clean themselves up. cities simply Chadwick delivery a system of water advocated and his allies The between poverty did not disease and epidemic relationship poverty long been plague had and cholera; the time of in originate the to probe some began and 1830s the 1820s in Yet linked. demographic detail. in more relationship René Louis Villermé’s economic one’s in the 1820s established that Paris research in factors,standing, and not environmental explained the ill health poorest. Villermé’s arrondissements of Paris’s of the residents revealedsimilar connections British counterpart, William Farr, Cholerain the urban centers of England. appeared as the result and industrialization of poverty brought on by the rapid This of way much of the West. spreading across urbanization thinking could comfortably contagion and miasma. accommodate conditions, perfect the poor lived in miasmatic be that could It Environmental for the spread of an infection cholera. like to dominate. came explanations for cholera Pandemics believing cholera those tobeacontagiousdisease, therewerestill believing In the1860s,asbalance ofopinionbegantosway toward what itwas. knew one yet precipitously. wasinthewater. It wasclear:something Butno lobbied tohave thepump handleremoved,cholera casesfell Snowsuccessfully pump.After same source,theBroadStreet thosewithcholera alldrankSoho, Snowrevealed, water fromthe who got sickgot theirwater. becameclear:in connection The wherethose cholera casesduring the1854epidemictodetermine In feat ofepidemiology, alegendary Snowmapped thelocation of to test. hewouldsoonbeable theory waterborne atheory—a wasjust cholerait was adiseaseinthegutandnotlungs.That transmitted frompersontothroughtheair, directly since the water supply. To Snow, cholera, unlike smallpox, wasnot wereinfiltratingSnow wonderedifthefecesofcholera victims publishing OntheMode ofCommunicationCholera in1849. thinking abouttheproblemofcholera duringthe1848epidemic, duringthe1854cholera epidemic. Snow hadbegun in London toJohnoccur Snowduringhispioneeringepidemiologicalwork tohim.Butitdid itmightbethewaterThat itselfdidnotoccur livingconditions. the effluviaofdailylifethat causeddeleterious that cleanwater believed wouldflush Chadwick away miasmaand squalid livingconditions,anddiseasewasclear. People like To urbanization, between whocaredtolook,theconnection most demandedit. interests driver behindtheclamorforcleanwater. Consumerandindustrial theprimary health ofthepoorwerenotalways, often, or even resultedinhealthiercities,concerns overthe water certainly great century. engineeringfeats ofthenineteenth Andwhileclean implement, wouldbe,alongwithParis’s oneofthe system, sewer Chadwick’s tofully vision,whichwouldtake ahalfcentury thatand sewage flushoutmiasmatic wouldconstantly waste. 68 Cholera 69 Koch’s and Snow’s work did not meet approval. with universal and Snow’s Koch’s The influential form, still held sway. often in attenuated Miasma, continued to argue von Pettenkofer German Max hygienist was not because he thought cholera supply, for a clean water was the key to good but because cleanliness in general waterborne health. Cholera came from the emissions of contaminated views a time, Pettenkofer’s For as the soil decayed. groundwater influencing, for had a powerful effect on policy, German sanitation decision regarding whether or not to provide example, Hamburg’s poorest citizens (they did not). to the city’s clean drinking water in 1892 and not to neighboring came to Hamburg When cholera those drinking water, Altona, where there was a clean supply of who believed theory in the waterborne by of transmission—which then included most medical scientists and others concerned with To prove remained firm. But Pettenkofer vindicated. cholera—were bacillus and containing the cholera water he drank his theory, full blown cholera. not, according to him, diarrhea—but developed factor it, the X As (the bacillus) was not enough in he saw The death knell for miasma, though it did not ring loudly at first,The at for miasma, though it did not ring loudly knell death bacteriological the fifth work in 1883, during was Robert Koch’s and tuberculosis pandemic. After the anthrax cholera isolating bacilli, Koch setWhen Koch discovered to work on cholera. bacterium in the comma-shaped cholera Vibrio cholerae and determined it must water be present that contaminated end of miasma was in sight. to cause the disease, the for whom miasma was the best explanation. In India, some some India, best was the miasma for whom explanation. In it disease because by the so plagued was the subcontinent thought and preyed population upon a weak by air, the soil, traveled was in sanitary The Indian to its ravages. uniquely susceptible up a cordon or putting ships thought quarantining commissioner no more logical “would be from traveling cholera to keep sanitaire or effectualwould be to post than it to a line of sentries stop the odds with where was at of seeing cholera But this way monsoon.” headed. medical opinion was Pandemics places ofrendezvoustheprocessions ofpilgrims. Jerusalem,Damascus, thedifferentplacesin Persia and thelarge Mahomedan placesofpilgrimage Mecca, Medina, Kerbalah, danger forEuropeliesintheinternational actual “The threat totheWest. awriterintheTimesofIndiaputit1892: As point.”departure It India: wasnotjust poseda theentireEast wehaveleast itsprogressascloselypossibleto tostop knowsit,fromtakinghistrips;at who livesinIndia, everyone delegate declaredin1872: “We have traveller that tostop cursed ontravelrestrictions fromtheMiddle andIndia. East Italian The By the1870s theconferenceshadbecomeaforumfordiscussing routeslinkedand steamship theMediterranean withtheRed Sea. travel from India toEurope.In two, 1865ittookjust asrail lines In pandemicsittookhalfadozenyearsforcholera to previous of 1865. transmitted duringthepilgrimage toMecca, thepandemic after increasingly concernedwithdisease,especiallycholera theincreaseinglobaltravel became and discuss andtrade. They asawaycalled regularlythereafter fornations tocome together International Conferences,beguninthe1850s,were Sanitary and aheightenedformofmedicalinternationalism. The ontravel, restrictions of neo-quarantinism, medicalinspection, diseases. Concernsaboutthespreadofdiseaseledtoanera andits East withthe“uncivilized” increasingly frequentcontact faster,were becomingever West bringingthe“civilized” into Contagionism tookholdat thesametimeasseaandlandtravel losing influence. such ashiswererapidly views But bythetimeofhisexperiment, (theZfactor). toproducealocallyborneinfection (the Yfactor) the absenceoflocallyspecific hygienic andclimatic conditions finds a fertile soilinthebodiesofpilgrims, weakened byall finds afertile the great placesofpilgrimage encourage thediseasewhose germ squalor andtheabsenceofany, policeat orany serious sanitary 70 . . . Oriental Cholera 71 The has been quite different than the seventhpandemic in general previous is affecting six. It new in a areas or areas not touched and Latin America; the former Sovietlong time, like Union very previousit has traveled fast; than any it has lasted longer strong for fortypandemic—it has been going years and shows no is less virulent than classical and El Tor anywhere; sign of going more easily. which allows it to travel cholera, The seventh effect greatest pandemic has had the in Africa—90 Echenberg rightly notes, the African percent of cases. As Myron a time when we at experience it that is forces a question: Why and possess a cheap and know more and more about cholera effective has the disease only grown worse and claimed therapy TB and malaria continue to the same reasons that more lives? For since the cholera: plague much of the continent, so too does 1970s, lack of health infrastructure, increasingly fragile all explain and poor sanitation economies, growing inequality, movements have population War-related power. staying cholera’s spread. aided cholera’s By the early twentieth century had become more or less a cholera Italy States. thing of the past in western Europe and the United robust efforts to in 1911, and the country’s suffered an epidemic it had and unwelcome hide evidence clear how rare of it make Europe. By the 1920s, the disease modernizing become in rapidly itself in the developinghad firmly lodged world, and the north lost interest. kinds of deprivations.” The “stranglehold on the east,” as Mark as Mark The east,” on the “stranglehold of deprivations.” kinds and Italy countries like time as relaxed over called it, Harrison in restrictions balk at began to Britain travel and Great on trade competitivean increasingly the demanded global market that unrestricted At the same time, the goods. flow of people and never has with cholera East, of the India, especially association disappeared. Pandemics temperatures—temperatures at whichcholera canthrive. ofrisingsea byandunabletomitigate theeffects affected most make thisworseascholera’s intothoseplaces reachwillexpand there’s areliablycleansupplyofwater. change Climate willlikely and symbolofsocialinequality. where It simplydoesnotexist disease,istheproduct morethananyCholera, otherinfectious 72 Chapter 5 Tuberculosis

Tuberculosis, caused by Mycobacterium tuberculosis, might be the oldest human disease. It is part of a family of mycobacterial diseases, including M. africanum, M. bovis, and M. cannetti, that have been evolving for perhaps three hundred million years. The oldest fossil evidence for a tuberculosis-like disease comes from a five-hundred-thousand-year-old Homo erectus skull found in Turkey with TB-like lesions. M. tuberculosis—the type that affects humans—emerged in Africa about seventy thousand years ago. It accompanied modern humans on their migratory paths out of Africa, first across the Indian Ocean and then, some millennia later, into Eurasia. TB flourished when people settled down and began living together about ten thousand years ago. It has been with us ever since.

Tuberculosis affects almost all parts of the body—the bones, the blood, the brain. Its most common and deadly form, carried in tiny droplets through the air from person to person and highly infectious, is pulmonary tuberculosis. It thrives in densely packed places.

Like plague, it is an ancient disease and has been written about for nearly as long. Tuberculosis was also discussed in terms of contagion and miasma. Retrospective diagnosis is tough. TB can look like pneumonia or other respiratory ailments. Centuries-old

73 Pandemics and more specific. Italian and British anatomists revealed and morespecific. Italian andBritish anatomists revealed Across theeighteenth century, descriptionsofTBbecame more medicine. onhorsebackwerethesoundest journeys Sydenham thoughtlong Thomas disease wenowcalltuberculosis. knotty swellingsinthelungs,hisdescriptionssound similartothe like modernTB,whenMorton talksaboutthetubercles,those leading toaweak,phlegmatic condition.Whilethese donotsound milkandtaxedtheirblood, toomuchbreast women expended theirlungsorwhen when peopleswallowednailsandpunctured many forms.For toMorton instance, TBcouldvariously occur century,end oftheseventeenth consideredconsumptioninallits Latin andtheninEnglish inatthe Phthisiologia, publishedfirst RichardMorton’show itisnowunderstood. comprehensive ways TB werequitedifferentthan The peopleonceunderstood 20 percent ofdeaths in thecity wereduetoconsumption. thatthe earlyepidemiologicalrecordsfromLondon—indicate century, earlyastheseventeenth diseases. As theBillsofMortality— Yet TBwasresponsibleforfarmoredeath thaneitherofthese century, nordiditarousepeopletomassacreothersasplaguedid. inflame thepressandpubliclike cholera didinthenineteenth bodily fluids.TBworksinsidiously, initiallyunseen.TBdidnot with TB,deadoraliveinamatter disgorging one’s ofhoursafter are notespeciallydramatic. Oneisnot suddenlyoverwhelmed divinely senttoroutsinandsinners.Unlike cholera, itssymptoms plague; itworked slowly. No onethoughtitthewrath ofGod, TB didnotriseupandsuddenlysnuffthelifeoutofmillionslike byasingleentity.disease—tuberculosis—caused phthisis, withunknownbutlikely myriad causes, becameasingle microscope in1882.Adiseaseonceknownasconsumptionand that Kochdiscoveredunderhis causesthediseasethat Robert foritwasthemycobacteria revolution, ushered inthelaboratory that TBwasthedisease cough—make diagnosesdifficult. definitive descriptions ofitssymptoms—nightsweats, weightloss,hacking 74 Tuberculosis 75 TB took a larger place in the culture and occupiedTB took a larger large, at the most prominent medical minds, because it nineteenth century’s Although it did not inspire the same kind of panic or xenophobia the same kind of panic or xenophobia Although it did not inspire and opera TB did become the subjectas did cholera, of literature La Bohème) and the tuberculous romantic (most famously Verdi’s poet comes readily to mind) occupied (Keats a peculiar place for a time in nineteenth-century female European culture. Upper-class the saw of a pale, wilting woman who rarely in the form beauty sun, preferringto languish for long hours indoors, was not weak. Asdissimilar to the consumptive: pale, thin, and TB so too mortality, assumed a more prominent place in European did it come to occupy aspects a more prominent place in various of culture. The of tuberculosis romanticization was but a small, overshadowed history, and short-lived, of the disease’s feature by its enormous effects on the lives of those whom it affected of the romantic poet the images Yet most—the urban poor. had have by TB or the wan woman prone on her daybed wracked power. remarkable staying tubercles in just about every part of the body. Vague descriptions descriptions Vague in justtubercles every about part body. of the nineteenth in the early to disappear began century after René Laennec of tubercle descriptions pathological all of the unified circulating.diseases then there the tubercle, he wrote, Without his observationswas no tuberculosis. the possible was Making the interior, for listeninginstrument to the body’s he invented stethoscope. Whereas previously a doctor diagnose TB by would history and observinglistening symptoms, Laennec to a patient’s revealinghomed in on the tubercle, it with his stethoscope and There between path was a clear after with an autopsy. death with microscope. Beginning stethoscope and Koch’s Laennec’s Laennec and who also focused physicians on single-disease other Paris focusorganisms, TB came into gained a name, as a single disease. It L. tuberculosis, when the Swiss professor of medicine J. in 1839 the ailments for which there were tuberclesSchoenlein unified all in 1882. title. Koch confirmed it all with his microscope under that Pandemics forty thousand. forty population ofeighteenmillion.In year, itsworst killed Cholera thousand people peryearinEnglandandWales outofa century,nineteenth bywhichtimeTBroutinelyclaimedfifty population fromtheendofeighteenthuntil middleofthe where anepidemicofthedisease ravaged theworking-class inEngland, 100,000. TBbegantotake tollfirst its industrial-scale comparison, today intheUnited States that figureisabout0.1 per ratesmortality ranged from 300to500per100,000.Byway of In century, halfofthenineteenth Europeduringthefirst western by, butitseems clearthat TBwasEurope’s leadingcauseofdeath. Recordsarehardtocome happened inEuropethenineteenth. century worldinthetwentieth What happenedin thedeveloping industrialization, andthecreation ofalaboringclass. modernity bya rapid increaseinurbanization, exemplified had becomesymbolicoftheharshconditionsmodernity— men become,notsomuchindividualsasunitsofproduction.” TB for humandignity inthelifethat breedstheseconditions,and burgeoning Africa,that urbancentersofEast “thereislittle care them,oftheincreasingamount TBinthe after nearly acentury Africa,echoed Marx inEast experience andEngels whenhewrote, Jenny.’ then whereEnglandwasat the“timeofinvention of‘Spinning commentator onthediseaseincolonies,wrotethat India was andfrequent 1930s, Lyle Cummins,aBritishTBexpert War II,itcametobecalledadiseaseofcivilization. In thelate modernity. TBincreasedinAfricaandIndia As World before just onacountry’s steps paththe 1930sthesewereseenasnecessary to wereindustrialization, urbanization,inextricable andTBthat by ofcapital.” conditionstotheexistence are thenecessary So “consumption andotherlungdiseasesamongtheworkingpeople cities like Paris Marx andLondon. andEngels wrotein1862that andthegrowthofcrowded,unhealthy development industrial century’snineteenth greatest killer. It increasedapacewith had firmlylodged itselfinthebodyofpublic. It wasthe ” Charles Wilcocks, a British doctor withconsiderable Wilcocks,aBritishdoctor ” Charles 76 Tuberculosis 77 Slum conditions in European cities were conducive to the spread Slum conditions in European cities were conducive of tuberculosis. This 1917 poster shows a streetof tuberculosis. scene from an This 1917 The grim reaper is looming in the impoverished area in Paris. background. afterWhile it is true that about 1850 TB began a hundred-year class were not decline, this does not mean the poor and working still suffering from TB. They were, and disproportionately so. theyhad been Once records began to be kept, bore out what 6. Pandemics in the bacillus, to him, TB, like in specific places; cholera, occurred Ransomebelieved caseforthesoil beingtheagent.strong Though Epidemiological Society,Ransomemade what heconsidered a people.Writingbetween in 1887 in the Transactions ofthe that diseaseswerenotpassed clungtotheview of thosewhostill Ransome, forone,wasaprominentexample Arthur contagionists. thedebate andanti- finally put torest contagionists between overnight,nor didit bacillus—did notcatch oneverywhere notionthat TBwascausedbyasingleentity—theThe tubercle causes ofTB’s amongsomepopulations prevalence andnotothers. of thevariety ofsocialandeconomic not denied,theimportance onthebacillus minimized,if cause. Overtime,theintensefocus health, cannotbeoverstated. From thenonTBhadonesingle ofKoch’simportance onmedicineandpublic work,itsimpact greatest killer, whichhecalledthetuberclebacillus. The theworldofmedicine.Hestunned hadidentifiedthecentury’s In Kochgave theearly springof1882,Robert atalkinBerlinthat racial minorities. affected it varied bylocation andsocialclass; italsodisproportionately began todeclineaboutmid-century. Butthedeclinewasuneven: TB theleadingcauseofdeath. Alsolike EnglandandWales, TB itwasacrossmuchofEurope,sotooinAmerica deaths. As 15and30percentofall Atlanta, TBwasresponsibleforbetween the 1850s,incitieslike Baltimore,Philadelphia,New Orleans,and growing industrialization accompaniedbymoreand more TB.In Germany, Russia, ortheUnited States, oneseessimilarpatterns: to decline,sotoodidoverall mortality. Whenonelooksat France, So great wasthe disease’s inEnglandthat whenitstarted impact to TB;98percentofthosechildrenhadbeenonpublicassistance. percent ofdeaths at theRoyalHospital weredue forSickChildren samewastrueinEdinburgh:39 children wereworking-class.The for approximately 80percentofthese 45percentofmortality; Hospital thatthe London TBaccounted revealed forSickChildren Postmortemimpressionistic. doneinthe1880sat examinations 78 Tuberculosis 79 Solutions to the TB problem included campaigns to outlaw to outlaw Solutions to the TB problem included campaigns housing. One of the to build more adequate and attempts spitting leastmost effective— popular and widespread treatments—and of the reasoning for the establishment of Part was sanatoriums. in the mountains of Silesia, was the beliefthe first sanatorium, TB did not occurthat above certain altitudes. First appearing in Germany up around northern in 1859 and then popping Europe around States came to the United craze the sanatorium thereafter, a Designed to give patients the turn of the twentieth century. The discovery TB was cause for celebration—and of the cause of overconfident predictions. The Times of London the rejoiced at of human lives which are now the “thousands that likelihood sacrificed everyat by the bacilli may year to the diseases produced no distant period be protected against these formidable enemies.” fanfare, less than a decade after international discovering great To found a cure.the tubercle bacillus, Koch thought he had But tuberculin, an extract hoped Koch tubercle bacillus that of the would act as a preventative, turned out to be useless as a cure (though quite effective as a diagnostic tool). Knowing the cause, it turned out, was only part of the solution to the problem. it was not passed from one person to another. Ransome ascribed ascribed Ransome another. person to from one not passed it was fetidTB to most seems fact, in probable, “It air: active for the that of the the virulence increase in some of the disease, propagation of intensification this outside the body, place organism must take mostits power being the presence of produced by commonly by the absence of in other words, the air, in matter animal organic is of a damp subsoil favoring influence ventilation.efficient The by the early twentieth century most However, also very distinct.” under health City, York New In considered it contagious. Biggs, TB became an “infectious and commissioner Herman and a system of mandatory in 1897, communicable disease” instituted was put in place. Some compulsorystates notification considered an assault on individual move some hospitalization—a liberty for the public good. Pandemics “The theory of artificial pneumothorax issimpleenough. ofartificial theory “The wrotein1919, anAmericanTBspecialist, Esmond Long, heal. As pneumothorax, and whichdeflatedthelung,allowing ittorest wascollapsetherapy, tuberculosis for pulmonary orartificial solutions couldnothave common The most beenmoredifferent. Surgical rested. was essentiallyapassiveaffair; one mostly wereotherattempts sanatoriumThere treatment The at acure. andplenty good oftimeoutside. allemphasized rest, diet, they them lacked thebucolicsurroundingsfoundat Saranac but Lake, werealsorunby thestate. Many Europe,they much ofwestern of government, also ran sanatoriums. In theUnited Kingdom and governments, and inthecaseofAmericanIndians thefederal sanatorium wasprivate, butotherswerepublic.State ormunicipal paid forthepoor;richbuilttheirowncottages. Trudeau’s Philanthropy people camefromfarandwidetoseekitscures. Trudeau’s boosters, loudest sanatorium proved agreat success: TBwasunclear, coldfreshairandcuring between toits even TBfromtheirlungs.Evenwould expunge thoughtherelationship fierce wintersbyloungingoutsideinthehopethat thefreshair Saranac New Lake, York, wherepatients braved thechallenge of adoptedtheoutdoorlifeat strenuously hissanatoriummost at It, waswhat cametobecalledthe“outdoorlife.” EdwardTrudeau 1899 Tuberculosis asaDiseaseoftheMasses andHow toCombat Recovery fromPulmonaryTuberculosis andS.AdolphusKnopf’s advocated insuchbooksasLawrason Brown’s 1916Rules for healthy outdoorliving didnot.In forTB, America,thecure Notions aboutaltitudeandTBchanged, on buttheinsistence and putthemintoahealthy place. environments tookpeopleoutoftuberculosis of the disease:they inaway,yet—sanatoriums, harked backtoapre-Kochianview drugsandnovaccine existed cure—no heal. Absentanactual air, sanatoriums, itwashoped,wouldallowpatients thetimeto respite frombusycity lifeandallowthemtoimbibefresh country the sameasthat orof lying,day backofbedrest inandday out,in 80 . . . [It is] Tuberculosis 81 TB remained a disease of the poor. In New York, the large the large York, New In TB remained a disease of the poor. inhabited crowded, poorly ventilated populations immigrant there were far in excess of those in more buildings. TB rates West Side of Upper In 1890, the well-off neighborhoods. where lower Manhattan, In had 49 cases per 100,000. Manhattan was 776 per 100,000. lived, the rate numbers of immigrants vast TB demonstrably declined across the developedTB demonstrably world, especially Britain, between the middle of the and Great States in the United nineteenth century specific of antibiotics, thanks to era and the and an improved standardpublic health measures of living. New formed in States public health departments in the United in cities part tuberculosis. to combat no single cause can explain But the Segregating population. reductionoverall of TB in the general infectious in Britain reduced TB in the cases in workhouses by reducing the risk of infection. population Thegeneral same was of infectious and segregation the identification York: true in New cases by the newly formed public health department allowed for to TB hospitals, thus population from the general their removal had some effect.reducing infection, sanatoriums and in this way Reducing the risk of spreading infection was and is essential to stopping TB. But the resources necessary only been to do so have in places where the standard of living has also increased. available The absence of improved living conditions has been accompanied to reduce infections.by an inability a reclining ‘cure chair,’—functional rest, rest enforced the cured of chair,’—functional ‘cure a reclining While Long deeply into “too go hesitant to was part [of the lung].” anecdotal evidence he suggested in what it worked statistics,” The had some positive procedure surely cases.” called “desperate artificial effects health matter cases, but as a public in individual TB problem, nor were not a solution to the was pneumothorax as they measures, as popular of these were, Neither sanatoriums. had any been in some cases, and as effective have as they may they when were effective,public health impact. they Even never served enough people. Pandemics thinking. In India race-based hadlittle explanations purchase,but ofthisway frequentlytheobjects of African Americans weremost “tubercularized.” BlackSouthAfricans,AmericanIndians, and hadnotbecome were uniquelyracially susceptible;orthey of the world—the“native races”—were virgin soilforTB;they over why TBwasincreasing.Peoples parts inthelessdeveloped For atime,variety ofracial dominated explanations thedebate Americas. andAfricaamongindigenous populationsmuch ofAsia inthe allmadeclearthat TBwasontherisein evidence and anecdotal healthdata, incollecting work,anincreasinginterest the survey leading causeofdeath. Precise numberswerehardto comeby, but had become,accordingtohealthofficialsinKenya, thecolony’s alarminglyhighTBrates.Africa—revealed ByWorld War II,it in theUnited States AfricaandSouth andCanada,inEast Maoris andAmericanIndians in New Zealand Nations andFirst inmany places—amongthe Surveys it increasedelsewhere. TBdeclinedinthegeneralAs world, population inthedeveloped killed offwhat wasalreadydying. itskiller.met However, amongthegeneral population antibiotics foehadnow aformidablediseasewithoutworthy performed: ushered intheantibioticera, itwasasifamiracle hadbeen Selman Waksman’s labdiscoveredstreptomycin in1944and marginalized populations intheUS antibiotics.Butwhen before from TB.Tuberculosis showed no signsofdecliningamong positive. In 29percentofallIndian Saskatchewan, deaths were Onehundredpercent ofPimasovertwentyinfected. tested approximately 75 percent oftheNative Americanpopulation was inthe1930sfoundthat intheSouthwest surveys prevalence ofthewhitepopulation.many BureauofIndian sectors Affairs hadfor oflivingincreasedasthey not beenreducednorstandards had Among AfricanAmericansinplaceslike Baltimore,infections five wasasmuch374 percenthigherthanforwhitechildren. forAfricanAmericanchildrenunder the wars,mortality Between 82 Tuberculosis 83 but it is difficult to the state exactly stage at what . . . Most western countries are said to have already passed through the already passed western countries are said to have Most epidemic stage the peak has not yet Some hold that been in India. disease is now the extent is still and that of stages, in the early India reached, that of the between that tuberculinisation is midway of the population and the highly industrialised European and urbanised African races not be correct Thisraces. but the factmay or view the is that may disease is rampant. Before World War II little had been done to combat TB among the had been done to combat II little War Before World several developments But then, very marginalized. quickly, world’s was the most productive what came together time to inaugurate in TB control the world had yet seen. The of postwar formation (WHO) and Organization Health the World like UN agencies UNICEF was part impulse—an impulse and parcel of the postwar Racial ideas were powerful, but not irrefutable. At the end of the they began to became available, data 1930s, as more and more British TB expert Charles Wilcocks Tanganyika, crumble. In surveydetermined black Africans that through an extensive X-ray had in fact been resisting lesions proved it. TB all along; healed simultaneously American Indians (Similar research among Wilcocks knew his finding was of that showed the same thing.) research would give “ground His more than “theoretical interest.” can be made effective, treatment and adequate for the hope that which in the conditions of life and education, the alteration that is the subject of all public health work, can help to control and generally Wilcocks’s As a result of work like tuberculosis.” II most TB War by the end of World changing ideas about race, reasoning. TB was a disease of had abandoned racial workers been eradicated, have explanations may But while racial poverty. TB had not been. evolutionary public 1933, the In did. civilization concerning ideas expressed belief a widespread of Bombay commissioner health in India: and urbanization industrialization, modernization, about Pandemics it spreadaround theglobe,itwasprovingtobe less than demonstrate that itworked wellamongAmerican Indians. Yet, as used extensively. In 1946,resultsfromacontrolled trialseemedto value fromtheFrench andBelgiancolonies,whereithadbeen considerably. thewar, Before ofits evidence therewas anecdotal cure. ButBCG’sTB; antibioticsoffereda ranged efficacy Kenya. Vaccination heldgreat promisebecauseitwouldprevent British Medical ResearchCouncil(MRC), especiallyinIndia and ofmuchtheworkWHO,the focus UNICEF, andthe hadintrials.Testingworld asthey BCGandantibioticsbecame serious problemsgetting antibioticstoworkaswellinthereal onBCG’s reports TB control—despairoverconflicting and efficacy challenge wasenormous.Hope mixedwithdespairintheworldof promise.Butthe bodies, andantibioticsshowedextraordinary BCG madeitsway aroundtheworldintotensofmillions drugs.”the useofanti-tuberculosis two mainelementsinthisprogrammeThe arevaccination and mass scale,aretoday, timeinhistory, forthefirst great. reallyvery foruseona acceptable tothepopulation, andnottooexpensive applied inapublichealthprogramme, willproveeffective, controlprogramme basedonmeasureswhich,when tuberculosis a possibilitiesfordeveloping the WHOputitin1958:“The As couldfinallysolvetheTBproblemwaspalpable. technology disease.” Bytheendof1950ssensethat biomedical onesingle knownagainst theworldhasever “largest massaction BCG vaccine campaign,waspreparedtolaunchwhat itcalledthe world.Indeveloping 1953theWHO, toitsplannedmass referring itin1908),thetimewasripetotackleTB developed forthetwo FrenchCalmette-Guérin—named who biologists large-scale AmericanIndian trialoftheBCGvaccine (bacillus TBandthepositiveresultsfrom cured antibiotics that actually World.called theThird of Combinedwiththerecent discovery what cametobe develop laborandconsumermarkets—to new in andminds,humanitarianism, andeconomicinterest for hearts sparked byavariety ofmotivations suchasColdWar competition 84 Tuberculosis 85 The on TB joined the simultaneous push to assault postwar a (successfully) as and smallpox malaria (unsuccessfully) eradicate TB, disease control. For narrowly conceived biomedical solution to this was never the robust enough. Critiques of this approach, like resistance movement against the mass BCG campaign in India and India In in the 1950s, were very seriously. taken rarely elsewhere, improving living standards the key was the notion that but it was of TB was all well and good, to lowering rates unrealistic, most in the development Many business thought. who McDermott, more agreed with American TB expert Walsh in biomedicine, TB was a “disease because of advances argued that Antibiotics incontrovertibly But they worked. were frequently to effectivelyrolled out in places unable them; supplies manage were expensive, and/or some drug combinations low; toxic, ran researchers from Facing these challenges, difficult to administer. developedthe WHO and the MRC regimens and cheaper drug possible. in the home was self-administration that demonstrated expertise, breakthroughs could not combat and But all the energy, times insurmountable, in some places a serious, at became what went from a decade, Kenya less than problem: drug resistance. In all to facing a nearly uncontrollable no antibiotics at having The same was epidemic of drug-resistant TB by the mid-1960s. true in other places where antibiotics existed in the absence of an For decades, the WHO and others effective system. management its seriousness. ignored the problem or downplayed promising. Then,promising. to date trial of the largest the results in 1979, efficacyhad 0 percent BCG appeared. south 360,000 among test subjects. has so widely its efficacy ranged Why has Indian never vaccine, explained. of been adequately Differing strains of infection, high rates mycobacteria, exposure to environmental exposure affecting to sunlight adversely BCG—all these going kept BCG offered. What been explanationsand more have the very it would work and that decades was the hope for so many powerful no other preventative existed. sense that Pandemics uncoordinated. Ifthissituation had beenawar in 2010 that theresponsetoTB/HIVhadbeen“timid, slow, and Anthony Harries,expert colleagues,thundered along withseveral thetideofHIV/TB.pandemic tostem RenownedTBandHIV little threedecadesofthe HIV wasdoneduringthefirst very early recognitionoftherelationship thetwo between diseases, health challenge unlike any otherfacedthiscentury.” Despitethe presentapublic “combined epidemicsofHIVandtuberculosis Tuberculosisagainst andLungDiseasewarnedthat the the problemthat in1994theWHOandInternational Union in theyearstocome.”slaughter ofmany victims] Soseriouswas could beat theroot ofahorrifying hecatomb [sacrificeor 1987 two researcherswrotethat the“combination ofbothdiseases one. at tofluoresceintoanactive allowingalatent TBinfection In effective withTB,anditisvery susceptible tobecominginfected companion forTB.It leaves thosewhoareHIV-positive more Because HIVweakens itistheperfect theimmunesystem, HIV/AIDS.challenge yet: continued tobeat it,facedtheirbiggest riskofcontracting away. workingonTB,aswellthosewho left Andthosestill disease.Butithadnotgone disappeared. TBwasaneglected By themid-1970s, inglobalTBcontrolhad innovation andenergy improvement inthesocialinfrastructure.” [that] canbedecisivelyalteredwithouthaving toawait lack ofleadership onglobalAIDS. ofHIV/AIDSneglect inAfrica,and continuedincoherenceand disease teamingupwithanoldone, theearly appearance ofanew flourish: globalindifferenceto TBbytheendof1970s, conspiredtoallowtheco-pandemic combination offactors number onekillerofthosewith HIV/AIDS. For decadesa 100,000 in1990to345per in2003.TBisnowthe rateits deadlycompanion,TBwent from aprevalence of146 per asaresultof Sub-Saharan ofall.Largely Africahasbeenhitworst andineffectual.”would have ashalf-hearted beenridiculed 86 . . . our efforts our efforts ic 8 B 9 36,000 7 M 1. 30,00 0 acif e: 1. 1 00,000 peopl e alence of y: n P 50–299 25–49 0–24 300 or mo re 1 50– 14 ev er alit positiv Pr est opulation: W P Incidence: Mo rt HI V- TB per 1 . 40,00 0 TB sia 8 B 1 A 1. e: t 3.5 M 480,000 rs y: sistant viet Unio n alit positiv s wo d’ ug- re opulation: rl ope South East P Incidence: Mo rt HI V- d s n Eur ll of the So , with d’ the wo eak of dr er rl TB . led to outbr East The fa gest anean Indi a The wo lar epidemic an estima te incidence of 2.2 millio n people rr 8,700 609 M e: 660,000 99,000 y: n Medi te er alit positiv opulation: East P Incidence: Mo rt HI V- : 870 ica 2.3 M 220,000 Afr y: . e an alit -positi ve ica pulation : 857 M Afr Po Incidence: Mo rt HIV 99 ything else 19 Sub-Sahar TB kills mor people living with HIV tha n an ose by y 50% ween ases r , London C nea rl bet and 2009. : 23,000 380,000 45,000 ding in 90 s. TB rk y: ections s an d ow Yo 19 er alit cr e a ope -positi ve ly w pulation : 900 M er ov Eur Po Incidence: Mo rt HIV Homelessness ov shelt Ne HIV inf dr epidemic in the ear ,000 37 e icas 260,000 21,000 y: alit Amer -positiv pulation : 943 M The Po Incidence: Mo rt HIV (TB cases): d of te er elat ison y TB tional alit TB-r WHO WHO mpar TB incidence

opor gion s gion s diamet talities Co of and mo rt Best estima te incident case s pr to by re Number of people fa by re Tuberculosis does not affect everyone equally. It is much more prevalent in some places than others. does not affect everyone equally. Tuberculosis 7.

87 Pandemics history. Tuberculosis nowkillsmorepeople thanat any othertimein Like HIV/TB,is notcost-effective. MDR-TB hasbeenneglected. more recent,thoughchanging,perceptionthat treating MDR-TB times, that TBissimplynotabigdeal; andthe drug-resistant program administration; at derelict theinsistence, shortages; control;drug patients nottakingtheirdrugs;poorinfection them, aconsequenceofantibioticsbeingmismanaged at alllevels: MDR andXDR-TB are,like TBbefore simpledrug-resistant faceoftheage-old problem.Both onitsface,isalsoanew new drugs—while one ofthefluoroquinolonesandinjectable toisoniazidorrifampinandat (XDR) TB—whichisresistant least antibiotics.Extensivelydrug-resistant commonandeffective most to isoniazidandrifampin,the sufferers areresistant at least two like Kenya inthe1950sand1960s,onlynowitisworse.MDR-TB acontinuation encounteredinplaces oftheproblemfirst actually scourge, itis billedasanew (MDR)TBproblem.Often resistant Added totheHIV/TB growingmulti-drug- pandemicistheever 88 Chapter 6 Influenza

The influenza that swept across the globe in two waves in 1918 and a third in 1919 was the worst pandemic in history since the Black Death. Influenza had erupted into pandemic form before— most recently, and severely, in 1889–1892. But none approached the impact of the World War I era pandemic. It killed at least fifty million people. Most of that death came during the apocalyptic months of October and November. Looking back, the British Medical Journal wrote in April 1919 that in Bombay influenza “caused a havoc to which the Black Death . . . alone affords a parallel.” It is still not known where the virus originated. Asia has often been cited. In Italy, rumors spread that it was not flu at all; it was chemical warfare perpetrated by the Germans. A pamphlet by an Italian doctor asked the question in its title: “Are the Latest Serious Epidemics of Criminal Origin?” The first known outbreak was at Camp Funston, Kansas, on March 5, 1918. From there it traveled to other forts and military facilities. It boarded ships bound for France in April. It spread quickly across Europe, reaching North Africa and India, and then going on to China and Australia by July. Flu struck so many longshoremen in the Philippines that dock work ground to a halt. The pandemic traveled the globe in four months.

The second, far more deadly, wave began in France in August 1918. It raced across the world via maritime trade and troop

89 Pandemics mortality was certainly greater than the reported figures. greater thanthereported wascertainly mortality records untilthe 1930s.Giventhevirulenceof disease,actual didnotbegin pandemic likelykeeping effects, haddevastating wherethe the limitedmedicalpersonnelkept records.China, few India andsub-Saharan Africa,demographic data werescanty, and death tollimpossible.In many hit,suchas oftheplaceshardest diagnosismake andinaccurate comingupwithaprecise reporting third oftheworld’s Incomplete population—were infected. staggering. were demographic effects Half abillionpeople—a The was over. pandemic in thewinterof1919andwasgone bythespring.The milderthirdwave The arrived inhabitedplaceontheplanet. every monthsthesecondwaveWithin afew hadwashed overnearly in Mombasa inlate September. the othersideofAfricaviaIndian Oceantrade, appearing first Flucameto backtotheAtlanticCoast. almost aboard steamship Itinternal transportationnetworks. followedtheCongo River of thecontinent’s well-developed andthemost ports busiest Flu’s asthenation hadone spreadacrossSouthAfricawasswift, arrived inCapeTown, itquicklymadeitsway viarailroad. north arewondering if thisistheendofworld.”some Lobis Onceit village, islike oneseesnoone.Ihearthat adeserted “Lorha north to Ghanawithoutwarning.Acolonialofficialnotedthat inthe made itsway openedrail lines.It intotheinteriorvianewly came buried intrenchesbecauseofalackroomthecemeteries”—it now are dead rats. .the like dying are down .people upside Freetown—where “isall that thecountry reported thenewspapers ofAfrica,in coast itlandedonthewest After occupation. thenunderJapanese city ofVladivostok, from theSiberianport famine-ravaged population. It arrivedinJapan onboardaship 10and25percentofthewar- where itkilledbetween Indian Asia. into northern andBritish troopsbroughtittoIran, Freetown, Trans-Siberian The Sierra Leone. Railroadcarriedit France; Brest, appearingsimultaneouslyinBoston; transport, and 90 Influenza 91 The pandemic reached some of the most remote communities in Islands the flu was devastating—mortality the Pacific the world. In Almost else. no in these islands than anywhere were higher rates Samoa Western island lost less than 5 percent of its population. of about 38,000 was the hardest hit: 22 percent of its population Some countries, and evenSome countries, and were hit much regions within countries, and harder than others; mortality on age also differed based Zealand, New people in Australia, and the Indigenous gender. times as much as four rates mortality suffered States United native the remote In than the surrounding populations. greater in far northern Alaska, influenza was a virgin soil of Wales village only 310. of people died out of a total population epidemic: 157 died, had by far the eighteen million where approximately India, from deaths as in other places, India’s Just toll. highest death among young adults. This concentrated flu—mysteriously—were was quite different than previous flu epidemics and routine yearly outbreaks in which the elderly and the very young were India women were hardest hit, In disproportionally affected. because they took care of the sick. One result of both the proportion mortality and the greater among age-specific of deaths in in India lowering of the birthwomen was a marked rate decline in 1919. subsequent years—as much as a 30 percent There couples were no more. were fewer women, and many The numbers have changed substantially years. Edwin over the changed Thenumbers have A Survey Influenza: in Epidemic by the , published Jordan Oakes total the global estimated Association in 1927, Medical American Thiswas 21.5 million. remained the standard for decades, figure fewbecause so had an interest But historians in the pandemic. Ashistorians low.” number “ludicrously to call Oakes’s come have revised more interest they in the pandemic, taken have have While little figures sometimesever upward, significantly. Oakes’s China, and is still the most Russia known about places such as may figure some think that million; is fifty recent global estimate percent. by as much as 100 be an underestimate Pandemics happened in an increasingly well-connected world where news worldwherenews happened inan increasingly well-connected initswake—principally, left the questions how couldthishave So appallingwas thedeath rate inWestern Samoaandsomany were asheroic. cheering theirownefforts responsetotheepidemicwhile islanders forthelackluster Yetcapable ofvigorous action. blamedthe Britishobservers of self-government.” 95percentmorbidity few rate The left incapable ofdeepfeelingandunfitted forthehighresponsibilities one’srevise estimate oftheTongan andshowthem character failings hadpoliticalconsequences:“Suchincidentscauseoneto Tongan urgent forthemost work.” wasprocurable moral These single a .not worst their at were conditions people. .When their of indifference ofthenative tothesufferinganddistress chiefs discouraging feature oftheoutbreakwasapathy and PacificThe Britishagent on islanders. most “The Tonga wrote: pandemic’sThe virulencewasblamedonthemoral failingsof administrative, andeconomiclifegroundtoahalt. percentofthepopulation Ninety overtaken. wassick;social, fluoutbreak.Withindays, theislandwas nature ofthisparticular Pacific world,noonewarnedtheislandsofunusuallydeadly British Empireandthediseasewaswellknownallacross Even thoughWestern ofthe Samoa,like waspart New Zealand, aboard theTalune ofthefluitself. effects , orfromthedevastating islandslearnedaboutthepandemicfromnewspapers call. The Noin New Zealand. onewarnedWestern of Samoaorotherports anddockinginWesternNew Zealand Samoaflu becameserious itstakingofffrom clean billofhealth,butintheweekbetween Talune.steamship Upon theshiphadbeengivena departure in Western Zealand aresult,fluarrivedaboardthe Samoa.As New tried mailboats fromdocking, suchmeasureswerenever preventing quarantining passengers onincomingshipsand Samoa bystrictly administration wasabletokeep flumoreorlessoutofAmerican States, seventymillionwouldbedead.WhiletheAmericannaval died inamatter ofweeks.Ifthat happenedtoday intheUnited 92 Influenza 93 Influenza is a virus—one with three types, of which influenza A is types, of which influenza is a virus—one with three Influenza the most lethal is a zoonosis—a disease and widespread. It That the pandemic was devastating is clear. The is reason why That was devastating the pandemic is clear. nor would the influenza was not new, but. Pandemic anything of been a regular feature have 1918 event be the last. Pandemics Flu has been a yearly human history since the sixteenth century. There had been a pandemic just a visitor for much longer. ones in and there would be later before in 1889–1890, generation But the 1918 1968, and 2009. There be another. will likely 1957, pandemic was different. The was yes. The answer commission determined that any caused the failure to relay bungling administrative the commission found, the British Further, on the flu. information the epidemic Samoa did not take in Western administration seriously enough; doctors their command of modern assumed that The of the disease. medicine would prevent the worst ravages Samoa. The not limited to Western was failure to communicate no one; the colonies themselves did a Colonial Office notified job of telling their neighbors if they had flu. better The of news best. Since flu was dissemination was haphazard at only when, not a notifiable disease, news reached a given colony Leonefor instance, Sierra to notify and the Gambia chose or someone read about it in the newspaper, neighboring Nigeria worst of all, when the flu itself appeared. or, traveled fast?—that in the summer of 1919 the British Colonial British Colonial 1919 the summer of in the fast?—that traveled investigate to Commission Epidemic the Samoan formed Office why Western islands and other Samoa pass to to was allowed influenza Samoa. of neighboring American out successfully kept when it was questionsOne of the “whether was the introduction and extension or default on negligence by any epidemic was caused of the said the part in the service persons of any the Crown, whether of in respect of the Executive Government Zealand of New or in respect Samoa.” of Western of the said Islands of the administration Pandemics virologists—who once thoughtthisimpossible—and publichealth virologists—who models offlutransmission andalarmed upended previous that avian tohumanshas discovery influenzacanpassdirectly avian—waterfowl, isinfact specifically.largest reservoir The happened. It hasbecomeclearerandthat influenza A’s definitively humans; human-to-humantransmission hasnot yet But sofarH5N1hasbeentransmitted to onlyfrompoultry from Hong Kong,knownasH5N1,jumped tohumansdirectly. Until 1997. yearavirulent,deadlystrain ofavian That influenza pandemics inhumans. influenzasin animals andperiodic circulating constantly the between conclude that pigswerethelikely intermediary influenzainpigsandpeopleledfluresearchersto between modern swineandhumanfluaswellthelong-termassociation similaritiesbetween genetic human andporcinelineages. The enough isknowntosay forsure,norisitclearwhensplitintoits that itoriginated inhumansandthen jumpedtopigs.Yet not lineages. Butwhenitarrivedin1918wasnovel.It ispossible human andswinestrains ofwhat arecalledH1N1andH2N2 thefall1918virus—isthat ofallfourthe least itistheancestor genomic sequencingofatwhich in2005allowedforacomplete especially so.What isknownfromarchival samplesofthevirus— Why remainslargely allthiswassostill amystery, itsseverity no timetorecoverorprepare. separatepandemic. Three waves, stacked oneatop theother, left pneumonia. Mortality wasmuchhigherthaninany otherflu and theold.Infection ledquicklytoadeadlyformof often which generally had(andhave) ontheyoung afargreater impact flupandemicsandtheregularseasonaloutbreaks, during previous features. It youngadultsat struck arate twenty timeshigherthan neuraminidase; bothareproteins)that distinguishing hadseveral strain of H1N1(where andNfor forhemagglutinin Hstands identify thevirusasa ittookuntil2005toeven been seenbefore; transmitted 1918strain hadnot tohumansfromanimals.The 94 Influenza 95 But medical science did not know that. Beginning in the 1890s But medical science did not know that. to be a bacterial infection— influenza was thought, erroneously, the infectiousGerman bacillus after its discoverer, called Pfeiffer’s During the pandemic Pfeiffer. Friedrich disease specialist Johann remedies. appeared, as did countless attempted a raft of vaccines Bacteriology worked. None was not until was of no use. It virology influenza was determined, enough that in had matured could prevent1933, to be a virus. During the pandemic nothing it or cure it. While we know a tremendous amount about the disease, there is While we know a tremendous amount about still us. That eludes much that elusiveness, combined with is humbling. at a The 1918 pandemic arrived power, influenza’s time when modern medicine had a newfound its confidence in Yet the causes of diseases and then offer to discover ability cures. before the development in the 1940s and beyond, of vaccines defenseless against influenza. it was utterly Because flu is such a shape shifter, a group of prominent influenza a group of prominent influenza shape shifter, Because flu is such a continuing progress in many “Despite researchers wrote in 2010, human and animal surveillanceareas, including enhanced and able are probably no better screening, we genomic viral large-scale and prevent pandemic of to anticipate the emergence today completely as shown by the ago, influenza than 5 centuries unexpected novel H1N1 pandemic virus.” of the 2009 emergence officials. Added to influenza’s ability to jump from animals to animals to jump from ability to influenza’s Added officials. often and rapidly is why (this it changes is that and back humans a newwe need or less vaccine more flu every via a autumn) drift. as antigenic process known Reassortment is a form of drift occursantigenic that virus are of the when different strains it seems, in happened, a newmixed to produce this is what strain; will H5N1 that future it is possible the and 1968. In 1918, 1957, between transmissible it becomes that way in such a change humans, causing a new of susceptible pandemic in a population hosts. Pandemics early October, Africa,thelocal whilefluwaskillingpeople inwest confident wasthe city initsability towardoffillhealththat in that alocalguidebookcalledit“the SouthAfricansanatorium.” So city considereditselfsohealthy weremuted.The initial reactions appearedinBloemfontein,SouthAfrica, When influenzafirst No waseffective. system abandoning Europeanmedicine forAyurvedichelped.It didnot. orthat that Africanresponses wereeffective, to suggest take isnot medicinemany consideredworsethanthedisease.This sent tothedreadedlazaretto (isolation hospital)orbeforcedto fearingthatkept suffererswouldbe outbreaksoftheflusecret, with death andsickness. In ofSouthernRhodesia,Africans parts medicine.” Africansassociated thetakingofEuropeanmedicine ofEuropean muchoftheirconfidenceintheefficacy people “lost convincing peopletoabandonindigenous medicinevanished as admitted andclinicshadmadein that theprogressdoctors were:quackery.what they Native reluctantly The Department admitted eventually doctors that Africanssaw for these“cures” Confident intheseremedies,colonialadministratorsat first and called “pneumoniamixture.” Othersusedparaffin andsugar. a combination plaster, of mustard oil,brandy, castor andwhat he “remarkableresults”from Belingwe, SouthernRhodesia,achieved offering awidearray of“cures.”The native commissioner in from Not having treatmentstop doctors actually didnot effective upanddoingthingsforourselves.”our welfareliesinstanding history ofourcountry.history It hasbeenmadetentimesplainer epidemic ought an editorialintheSierra LeoneWeekly News toopine,“The colonialauthorities’handlingofthepandemicprompted Leone, inAyurvedic andUnani interest renewed medicine. In Sierra local peoples’tiestotraditional healers.In Bombay, thisledto of with theineffectiveness strengthened medicine,which Western displeasure expatriateregistered Colonial officialsand doctors frequently criticized“native” medicineitwassupposedtoreplace. In thanthe thecoloniesmodernmedicinewasnomoreeffective . . . to be made a distinct point of departure inthe pointofdeparture to bemadeadistinct 96 . . . that Influenza 97 counseled Journal British Medical On the advice of doctors, London’s Local Government Board did On the advice of doctors, London’s Because of cinemas be well ventilated. more than order that little which was capable of theory, of their faith in the germ the strength silence and inaction: one editorial said, “When epidemics occur, silence and inaction: one editorial said, “When epidemics occur, more if a little it not be better happen. Would always deaths prudence were shown in publishing such reports instead of dark clouds as possible to upsetbanking up as many our Guardian echoed this breakfasts?” An editorial in the Manchester public is a big ally of the influenza, and if the sentiment: “Terror of mind can be steeredstate of the channel of fright a long, out to conquer the epidemic.” been taken long step will have As Overreaction was frowned upon, especially in the face of war. since the Black Death in December: “Never the Times remarked perhaps, world; never, has such a plague swept over the face of the has a plague been more stoically accepted.” England, a country with one of the most robust public health infrastructures, responses. Armed of the weakest mounted one convinced were physicians with a newfound theory, in germ faith theythat they could tackle the disease and refused to accept that many had no real preventative or curativemeasures. Further, progress, believedmedical professionals fear fostered flu’s that health about spreading the disease. Public causing people to run calm.officials urged in This, combined with their overconfidence the the severity of them to downplay modern medicine, led the like Publications pandemic. newspaper ordinary friend the “our dangerous how wondered be. could influenza” or garden common They had an answer soon overwhelmed. became and hospitals piled up as bodies An elder seemed “It Reformedof the Dutch Church in October, said later The shock thrust the end of mankind.” it was the to me that into action—cinemasmunicipality local schools were closed; and available “flu mixtures” their pharmacists to make were compelled were conscripted black South Africans charge; no at to the public as laborers to dig graves. Pandemics during World War I. 8. GovernmentBoard,wrote: Local medicalofficerofthe chief Newsholme, both awarabroadandpandemicat home.Arthur of resourcesgenerally. It provedtoughtomobilizeBritainfight the availability (somany wereaway), ofdoctors ontheavailability flu’s effects. World morale, on WarIhadaprofoundimpact—on towardmitigating someofthe insufficient resourcesweredirected were imminent, andpreventions lulling peopleintothinkingcures Fearing theflu,soldiersdonnedmasks towatch afilmin France have been regardlessly prohibited. But it was necessary to “carry on.” to“carry have beenregardlesslyprohibited.Butitwasnecessary workplaces,barracks andships;ifovercrowdingcould factories, increase offloorspaceforeachpersoncouldhave beenenforcedin isolated fromthehealthy; ofknownsickanddrastic ifrigidexclusion diminished, somesuffering been avoided, iftheknownsickcouldhave the casescitedsomelivesmighthave beensaved, spreadofinfection as regardsinfluenza. on,” duty whenrisktolifeandhealthisinvolved. hasarisen This even inwhichthemajorduty isto“carry arenational circumstances There other workers engaged inworkofnational importance. . . . It hasarisenamongmunitionworkers and 98 . . . In eachof Influenza 99 Despite its failures, the appeal of modern medicine was scarcely Despite its failures, the appeal of modern medicine diminished. The laboratory revolution had ushered in a new age; and public health physicians many there was no turning back. Yet experts Thinking their limitations. were willing to admit back on Rosenau wrote the pandemic in 1919, the bacteriologist J. Milton Association, “If we have of the American Medical in the Journal we know we are not quite sure what it is that learned anything, This kind of admission was not uncommon, about the disease.” it did not lead to despair; it States least United in the and at pointed medical scientists toward opportunities. In the United States, initially, the Public Health Service published Health the Public initially, States, the United In pamphlets suggested that across the country the flu spreading was In the face of annual flu. no worse than the average in most ways continued health commissioner City’s York mounting cases, New throughout the first the weeks of October 1918 to downplay could handle it, the city Confident that seriousness of the disease. things to remain calm; fear would only make he cautioned citizens most the country’s civil authorities forced Italy, worse. In , to stop publishing the della Sera Corriere influential newspaper, toll as fear and anxiety mounted. Thesedeath initially cavalier to action places as municipalities in many responses did give way medicine was still realized the seriousness of the pandemic. Yet ineffective. Over the course of a fewthe course Over flu killed fall of 1918, weeks in the Doctors in England. people 250,000 distracted and others by war but as theyas seriously epidemic the take did not have, might As of the crisis. did recognize the magnitude people the many its and so ubiquitous was the catastrophe vast Times put it: “So surfeited our minds, prevalence that war, with the horrors of the went, a hurricane across came and refused to realize it. It in hundreds of our youth away of life, sweeping green fields sickness and infirmity behind it a toll of thousands and leaving in this generation.” which will not be reckoned Pandemics long after thepandemic wasgone. long after Rhodesia inthe immediate oftheflu’s aftermath arrival remained ravages ofthe flu. churchesthatPentecostal emerged inSouthern appearedtosave byGod, theirpeoplefromthe directed prophets, formedwhen inZaire,forinstance, Church Kimbanguist Aladura churchesinNigeriaor spirit,churches.The andthe aroseaseriesofPentecostal,and South Africa,forexample—there In many placesinAfrica—SouthernRhodesia,Nigeria, Zaire, don’t know. where nearlytwenty millionpeople died?Perhaps, butwe of thetime.ButcouldsamepossiblybetrueinIndia, pandemic rarely features inany way substantial inhistories toit,the bookssolelydevoted literature. fromthefew Aside or inmemory but forgotten. isbarelydetectable Its impact to have pandemichasbeenall hadlittle inAmerica.The impact demographic effects? From what little wedoknow, it seems economic,political,social,and But what ofitscultural, that isnowconsiderably morerobust. system better ofinternational system influenzasurveillance—a Worldafter War II,butthepandemicdidspawn ina aninterest remainedmoribunduntil system The andreporting. surveillance notifiable disease,thereemerged ofempire-widedisease asystem andSouthAfricatomakeas callsfromNew flu a Zealand seem clear. For inthePacific, one,asaresultofthedisaster aswell generally. remain.Somethingsdo Butmany questions historical virology and on twenty-first-century twentieth- profound effect pandemichashada implications ofthe 1918pandemic.The amountofresearchintotheoriginsand sparked anextraordinary did notamounttotheglobalnightmarethat waspredicted— appearance ofH5N1 andthe2009swineflupandemic—which haveresearchers, nothistorians, taken The thekeenest interest. onthepandemicitself, notwhatfocused cameafter. Biomedical pandemic’sThe arehardtogauge. effects workhas historical Most 100 Influenza 101 ” announced the city’s town clerk and town clerk the city’s ” announced shocked at the revelation of slums and degradation the revelation of slums and degradation at shocked . . . The 1918 influenza pandemic was an event. Unlike malaria and Unlike The 1918 influenza pandemic was an event. tuberculosis—the perpetual pandemics—influenza comes and or plague. Of course smallpox it is more like this way In goes. is. Influenza major global threats. diseases are no longer those two and the novel strain When H5N1 appeared in humans in 1997 of the of H1N1 turned up in 2009, the world was reminded do has not happened yet. of another 1918. It We possibility English in the the like are rather not know when it will. We They knew plague was out there, that seventeenth century. and theylurking, ready to strike, were more or less resigned to its return. They it would come back; did not know when or why Protecting know how: by ship from abroad. they did, mostly, themselves, once they plague out knew by keeping it was coming, potential of warding off an had any was the only thing that a robust global monitoring now, vaccines have epidemic. We , wrote, “The newspapers, the Friend One of the city’s treasurer. of the public conscience has been a stimulating result immediate social reforms.in the direction now Schemes are of long-delayed dreams as the regarded yesterday which were under consideration are demanded as urgent of impracticable visionaries, and to-day Reform had been tossed about before, but it took the necessities.” into action. told the city pandemic to shock the As the mayor had long had Epidemic Commission, “Bloemfontein Influenza but the experiencesuch a scheme in contemplation, in the public opinion, and stimulated epidemic had hastened matters can only one now, For these reforms.” which was now ripe for caused similar reformswonder if the pandemic elsewhere, to say effectsnothing of its possible on other aspects of life. disclosed by the ‘Flu’ disclosed by In Bloemfontein, South Africa, the pandemic sparked a number of a number sparked the pandemic Africa, South Bloemfontein, In a move invigorated and health laws in public changes immediate fact to face the was forced poor relieftoward it the city as that “The as slum-free as it imagined. or was not as healthy citizens were Pandemics possibility of a deadly pandemic. This isamistake.possibility ofadeadlypandemic.This lackadaisical outlookwhenitcomestogeneral concernaboutthe thingsallcanadduptoagenerally would be.These they amounted tomuchlessthanmany publichealthofficialspredicted with acold.Boththe1976swinefluand2009’s H1N1pandemic concern.Forbe hardtomuster many, fluissimplysynonymous officials donotpossessanunhealthy amountofconfidence,itcan andpublichealth the flu,andunlike virologists in1918most While wearenowsufficiently awareofthechallenges oftackling influenza pandemicwillhave wildlydivergent effects. ensurethat, asin1918,any just future co-infections—will andrampantmedicine, compromisedimmunesystems, inadequate accesstopreventive public healthinfrastructure, oftheworld—amongotherthingslack resource-poor parts things thatandmalariaalivewellinthe keep tuberculosis Further, ofadeadlypandemicmany ofthesame intheevent anxiously watching theshore. Yet counterparts like wearestill ourseventeenth-century andinsomeplacesawell-runpublichealthinfrastructure. system, 102 Chapter 7 HIV/AIDS

The arrival of HIV/AIDS was the end of the age of hubris. Any bluster about the death of infectious disease by the hand of biomedicine or hope of living in a world free of pestilence disappeared as it became clear that HIV/AIDS was a new infectious disease thriving in a world thought to be on the verge of being free of such menaces.

HIV/AIDS had been percolating in central Africa since the early twentieth century, but it appeared in its now recognizable form in the spring of 1981, when doctors in Los Angeles and New York City began noticing a strange uptick in rare diseases like pneumocystis carinii pneumonia (a fungal infection to which immunocompromised individuals are susceptible) and Kaposi’s sarcoma (a rare form of cancer, mostly found in the aged). Even stranger was that they clustered in sexually active gay men. Then, over the next year or so, other groups, including hemophiliacs and intravenous drug users, became similarly afflicted. People from Haiti, too, seemed to be struck down. A Belgian doctor, Peter Piot, keeping up with the news from Centers for Disease Control, recognized similarities between what he was reading about in the United States and what he was seeing in his clinic in Antwerp—a clinic frequented by African immigrants. More and more reports from other parts of the world began popping up of unexplained cases of Kaposi’s sarcoma and an assortment of immune disorders.

103 Pandemics medicine’s confidenceinitsownpowers. ofavaccine modern andforatimebolstered hasty predictions on AIDSresearch)ledto spent farmorethan any othercountry government spendingonmedicalresearch(theUnited States identification ofthevirusandseeminglylimitless US federal biology, immunology, saw rapid andvirology tothat. The whatunderstand caused plague.Decadesofadvances inmolecular came tomedical first attention isremarkable—it tookmillenniato ofHIVonlytwo AIDS yearsafter of otherdiseases,thediscovery When consideredalongsidetheagents responsibleforthecauses 42.6 percent. rate aprevalence prenatal of clinicsin Swazilandrevealed problem ofthegeneral population. In 2004,data from population; incentral, andsouthernAfricaitisa eastern, ofthe sociallymarginalizedportions mostly AIDS affects Middle America,Japan, Latin East, ofEurope,HIV/ andparts have insouthernAfrica.In occurred someplaces,like the equally:wellmore than athirdofallcasesanddeaths affected has beenuntouchedbyHIV/AIDS. is Butnoteverywhere casesappeareachyear.of new No oftheinhabitedglobe part nearly seventy-fivemillionpeopleworldwide. Tens ofthousands HIV/AIDS millionandinfected hasnowkillednearlythirty virus. name: humanimmunodeficiency the solediscovery. Butsoonthemedicalcommunity settled ona different;eachclaimedcreditfor virus. Eachcalleditsomething the National CancerInstitute intheUnited States identifiedthe 1983 and1984,respectively, thePasteur Institute inFrance and syndrome). Not longafter, immunedeficiency AIDS (acquired in name: the summerof1982itwasgivenitsformalandlasting CDC labeleditGRID(gay-related disease). immunodeficiency In community snappedtoattention. Initially the (andunfortunately), The biomedical fought offbyahealthy immunesystem? ofdiseasesthathost werebothrare andgenerally abletobe What linked all sufferingfroma thesegroups?Why werethey 104 HIV/AIDS 105 HIV 1 and 2 are both zoonoses (diseases originating in animals zoonoses (diseases originating HIV 1 and 2 are both infect now types of HIV is that the different humans), and each of (HIV-1) from chimpanzees transmissions an instanceof separate The of HIV genetic greatest diversity mangabeys or sooty (HIV-2). are found there, as are Africa. All group M subtypes is in central is genetic makeup recombinant forms in which the virus’s many geneticdifferent this is the region means still. Such diversity where HIV has been developing and is thus the origin the longest point for the pandemic. The virus passed from chimpanzee to human sometime around the turn of the twentieth century when, infected blood entered the body of a chimpanzee more than likely, hunter through a cut or open sore. By about 1920 HIV had made area around Léopoldville (since 1966 Kinshasa). to the its way across Africa along ever developing there it made its way From places in various speed accelerated networks.transportation Its medical campaigns against sleeping and times: colonial era reused needles, thus and syphilis frequently sickness, yaws, numbers of quickly to large allowing the virus to be transmitted for them to female prostitutes HIV by treating people. Passing syphilis with non-sterile of needles was an especially effective way in the 1950s and 1960s. population HIV into the general getting Once enough prostitutes were infected, spread, especially in HIV of Léopoldville in the changing environment the dramatically But the optimism did not last. Identifying the virus was not the virus was did not last. optimism But the Identifying be a complex out to HIV turned enough. retrovirus several with and identities. different are actuallyThere HIV-1 two viruses: West to confined is largely is more prevalent; HIV-2 HIV-1 HIV-2. HIV-1 and harder to transmit. is much slower moving Africa and further O) and then into eleven N, into groups (M, down is broken genetically distinct M (the main group) is (A–K). Group subtypes percent of as it causes 99 for the pandemic, the one responsible A, of cases, cases. Subtypes majority the vast up C, and D make C accounts for most cases in southern about 84 percent. Subtype and China—and proportion thus for a huge of the Africa, India, HIV. world’s Pandemics than 500,andthe individualisasymptomatic. Onceat stage 2 of blood.Atstage 1the CD4countisusuallygreater millimeter healthy individual’s CD4countismorethan1,000cellspercubic HIV progressesthroughfourstages basedontheCD4count—a infection. after shortly infectious most is measuredbyviral strength load;apersonis oftheinfection The inthebodyandvirusbecomes detectable—occurs. develop seroconversion—the processbywhichHIVantibodies infected, torecognizetheseinvaders.and allowtheimmunesystem Once andthemacrophages, which seize foreignbodies and infections, cells, whicharethebody’s foreignbodies against maindefense theThelper types ofCD4cellsessentialforfightinginfections: system’s isthattwo HIVtargets CD4cells.Especiallyimportant which thevirustravels. Onceinthebody, HIVattacks theimmune routesby men having withmenareallcriticallyimportant sex transmission, needlesusedforintravenous non-sterile drugs, and transmission common.However, ismost mother-to-child effective.Heterosexual fluids—blood andsemenarethemost impossible. HIVmakes itsway intothebodyviainfected unpredictably, farithasproven makingavaccine isdifficult—so and thevirusmutates. BecauseHIVchanges sorapidly andso conversion, HIVmakes many, many mistakes incopyingitself, transcriptase, asRNA.Duringthe enzyme calledreverse to DNA andthenmakes material, copiesofitsgenetic viaan RNA (ribonucleicacid).WhenHIVinvades itself acell,itconverts whichmeansthat HIV’sretrovirus, material genetic isfoundin material viruses,isDNA. But HIVisa ofalllife,includingmost genetic slowlyduringalengthy The incubation. very it develops tocontrol. difficult HIV isvery Forone,becauseitisalentivirus, It oftheworld. thenspreadtotherest like thetwo UNESCOmigrated between countries. backandforth the many Haitians employedbyvarious United Nations agencies From inprostitution. explosion thereHIVmovedontoHaiti as 1960s—mass migration tothecity, highunemployment,andan 106 HIV/AIDS 107 But the biomedical breakthroughs have not always been in sync not always But the biomedical breakthroughs have but access to is now treatable, with life outside the lab. HIV/AIDS drugs is uneven, and new infections that continue to demonstrate From the very preventiononly partly been efforts successful. have with been fraught beginning of the pandemic the response has for example, States, where the United In challenges. many many, with sexuallythe disease has primarily been associated active and moral drug users, panic, fear, men and intravenous gay opprobrium were common reactions. Conservative such senators men: AIDS was retribution for sinful blamed gay Helms as Jesse a demonstrable which have programs, exchange Needle behavior. been controversial, thought by always public health benefit, have perceived government to promote illegal drug use. Many many Added to all this are the political and social factorsAdded to all this are the determinethat and poverty, gender, its control. They sexual behavior, involve Yet well as political will—or lack thereof. access to medicine, as triumphalism, a time of scientific arrived at because HIV/AIDS felt powerfully a community a time when the biomedical that bestbiomedical solution was was imminent, there has always and been a tension between aspects the social and medical of dealing broadly speaking, the biomedical response with pandemic. Very has been nothing short An entirely new of breathtaking. scientific industry Breakthroughs in understanding were has been created. and frequent. Asrapid a result, the disease went from a nearly virtually affliction fatal, untreatable to a manageable always chronic disease in less than a generation. CD4 has dropped to between 350 and 499, and symptoms like to between dropped CD4 has like and symptoms 350 and 499, 3 CD4 stage In appear. fungal infections loss and weight may The below 350. has dropped count is severely individual opportunistic to many and susceptible immunocompromised below 200, the CD4 count is AIDS, when infections. Full-blown stunning are its main features 4. Asis stage a virus, HIV’s the very to disable ability and insidious complexity system repel it. designed to Pandemics Africa, denialism reachedapeakinthemid-1990s whenPresident stigmatizingconfine theirepidemics bynot theill. In South publicly confronted AIDS,admitted itwas present,andworked to was attached Uganda wereexceptions: toit.There andSenegal considered AIDStobeagay disease,andthusconsiderable stigma andareboth indigenous and endogenous.and complex Most reasonsarevaried point andtheepicenterofpandemic. The was Africa, whichwasboththeorigin neglect One areaofstriking fragmented, andinconsistent.” delayed, part grosslyinsufficient, response “wasforthemost physicians fromthe pandemic’s earlyyearsclaimedthat the global were lessso.Writing prominent inTheLancet2008,several pandemic wasextraordinary. political andsocialresponses The thebiomedicalresponseto and breakthroughsachieved, If measuredindollarsspent,paperspublished,careerslaunched, havingZimbabwe, deniedeven thediseasewithinitsborders. individuals had.Othercountries,suchas partners sexual for andpromotingacampaignaimedat reducingthenumberof advocating confronted theepidemichead-onrightfromstart, and mandated fortheentirecountry. testing In Africa,Uganda isolation ofthosewhowereHIV positive strict Cuba instituted approach. countries werepassive,whileotherstookamoreactive have beensovaried that generalization isnotpossible.Some Outside theUnited States thenational responsestothepandemic offinthe to level United States, theuseofcondoms diminished. tousethematmen simplyrefused all;andastheepidemicbegan slow totake andsome holdamongmenwhovisitedprostitutes, way thebest abstinence toavoid HIV/AIDS; condomusewasalso programs ranSafe-sex intooppositionfromthosewhoconsidered ACT UP, emerged tochallenge bureaucratic dithering. exemplified by movement, AIDSactivist andeffective a powerful drugsinatimelymanner. at approvingnew ineffective As aresult, agencies like the Food andDrugAdministration tobeslowand 108 HIV/AIDS 109 Once the GPA was created and Jonathan Mann (who had been (who Mann and Jonathan was created Once the GPA on to become and who would go in Congo SIDA running Project world) hired to run it, global AIDS in the HIV/AIDS a legend to WHO donations received unprecedented attention; and had success in working with Uganda The GPA skyrocketed. and Mann Thailand reduce transmission, to dramatically The The consequences for Africa were great. dismissal of States heterosexual as unimportant transmission in the United heterosexual the burgeoning meant that pandemic erupting in Africa—so effectively documented work of by the pathbreaking initially ignored. This in Congo—was meant too that SIDA Project the burden of HIV in women went unexamined. By the time the on AIDS (soon renamed the WHO started Programme its Special the pandemic had in 1987, on AIDS; GPA) Global Programme been silently spreading more or less unabated. The WHO was slow to take notice. Four years into the pandemic, years The notice. Four to take WHO was slow still the director consider HIV/ did not general, Mahler, Halfdan a bush fire like is not spreading “AIDS stated, He AIDS a priority. are killing millions that and other diseases is malaria in Africa. It much looked the pandemic Further, of children every day.” and much of Europe, States United In the different in Africa. of research was being conducted, majority where the vast the drug users. disease most men and intravenous affected gay policyBiomedical research and focused largely disease’s on the where the research was taking place. profile in the countries a and not considered rare was initially transmission Heterosexual Reliefdriver of the epidemic. set in the United in among some confined to “high AIDS was largely as it became clear that States of heterosexual feared wave risk” groups; the tidal many AIDS never came. Thabo his minister Mbeki and the following argued, of health cause AIDS did not HIV that Duesberg, denialistAmerican Peter newlyand thus and effective emerging be useless. would drugs Pandemics half after the first case appeared, they wrote,“theworld’s case appeared,they thefirst half after leaders, to thepandemic, itpullednopunches:duringthe decadeanda UNAIDS oftheglobal response publishedits book-length history muchvaluable inthe1990s.When groundwaslost calculation andcraven Duetoprofoundneglect on HIVprevention. political world,itonlyreceived6percent ofglobalspending the developing thoughthemajorityand bytheearly1990s,even ofcaseswerein global stage duringthe earlyyearsoftheGPA, attention flagged, the occupied inAfrica.WhileAIDSbriefly increase exponentially sameyearsthat thepandemicbeganto these werethevery world.And,tragically, ignoredAIDSinthe developing virtually movement intheUnited States andtheUS government itself epidemicthat onthe domestic boththeAIDSactivist they Not many peoplewerepaying attention anyway. were Sofocused the GPA—global HIV/AIDS leaderlessandadrift. wasleft UNAIDS reachingoperational capacity—albeit farbelowthat of In thetransitional years from theendofMann’s tenureto agency, UNAIDS, inoneplace. toconsolidate activities inaneffort after, theWHOclosedGPA. AIDSworkmovedtoanew general, Hiroshi Nakajima. GPA The momentum.Not lost long repeatedly clashingwiththedirector resigned in1990,after But HIV/AIDS’s Mann timeinthespotlightwasshort-lived. leader intacklingglobalAIDS. that adiseaseappearedontheassembly’s agenda. WHOwasthe inthefallof1987, Assembly General timeinhistory itwasthefirst funded program. WhenMahler andMann addressedtheUN toitsdownfall—and wasWHO’swhich ledinpart largest andbest GPA onTB.The impact operated moreorlessautonomously— HIV washaving andwouldcontinuetohave aconsiderable attempted tothinkofTBandHIVinunison, recognizingthat Fordiscrimination and persecution. time,theWHO ashort andensurethatreduce stigma individualswouldnotsuffer GPAThe alsomadeHIV/AIDS to ahumanrights issueinaneffort successfully turnedtonongovernmental organizations forhelp. 110 HIV/AIDS 111 During these years, too, the World Bank gained in importance the World During these years, too, year GPA the same while the WHO declined. Beginning in 1987, more health programs opened, the bank began funding more and principles which meant, among other things, based on neoliberal health interventionsthat based on analysis of would be evaluated cost-effectiveness; countries’ public health many also meant that it budgets declined. As sharply and larger the bank took on a larger gained more and it naturally role in funding health programs, One of the like. looked those programs more influence over what most powerful effects was coming to see disease interventions in terms of cost-effectiveness. of prioritizing programs This new way Development 1993 World Bank’s made its debut in the World , which signaled to the world, Report: Investing in Health a shift according to an editorial in The Lancet, that had occurred Health health from the World “in leadership in international The bank sought to identify Bank.” to the World Organization had the most(and the WHO followed along) which diseases deleterious are called effects in what on the economy—measured Beyond neglect, simple aid to developing overall countries the 1990s. UN in the 1980s and into declined dramatically the like donor nations WHO suffered when the like agencies dues Reagan years refused during the to pay States United was an exception, as it received a time the GPA (though for policies forced countries economic funds). Neoliberal earmarked burdens of down their large in order to pay to accept austerity an enormous effect on economies to have began debt. HIV/AIDS same time as the effects the at of structural adjustment programs reserves already meager continued to sap countries’ justwhen they needed resources the most. The effects were staggering. One funding for healthcare plummeted; was that result, among others, few African countries introduced user fees—fees patients many were able to pay. in all sectors of society, had displayed a staggering to indifference displayed had sectorsin all society, of of this new challenge the growing epidemic.” Pandemics baby just after hasa dramatic onthisrouteof transmission. after effect baby just andthe birth before tothemotherjust giving adoseof nevirapine transmission is)achallenging problem,but hadbeen(andstill itstransmission tobabies.Mother-to-infantcould alsoprevent notonlyhelpedthosewithHIV;of thesedrugs,nevirapine, it A diseasethat hadbeenadeath sentencewasnolonger fatal. One the patient’s restored. immunesystems used inatriplecombination, theviruscouldbesuppressedand announced that when drugsfromthesetwo differentclasses were International AIDSConference inVancouver researchers Attheeleventh inhibitors, beginningwithnevirapine. saquinavir, transcriptase andthenthenon-nucleosidereverse wereproteaseinhibitors—first andreleased:thefirst tested, drugshadbeendiscovered, 1996 two classesofantiretroviral new samecannotbesaidofbiomedicine. Ininadequate. The 1995and global politicalresponsetoHIV/AIDS inthe1990swas opportunity. andlost 1990swasadecadeofneglect The The inneed. fromreachingthosemost biomedical intervention aneffective werenowpreventing ofsocialinterventions neglect that ledtheUnited States tofixate onabiomedicalsolutiontothe sameeconomicimperatives very The HIVinstead. on preventing have towork toomuch.It it;itcosts wouldbemorecost-effective (HAART)—the itcouldnot globalsouthwastoldbythenorth therapy antiretroviral technological fixwasinsight—highlyactive astheholygrailposition: just oftheglobalnorth’s pursuitofa countrieswereinastrange, perhaps ironic, developing Thus hardtoimplement. werevery butthey considered cost-effective, suchascondoms,were efforts, countries. SomeHIVprevention inlowincome werenotcost-effective they was expensive, drugs emergingclassofantiretroviral Becausethenewly effective. thingsinsuchterms,treating AIDSwasnotcost- calculating totreat. Byanyinexpensive measure,accordingtothose DALYs (disability-adjusted lifeyears)—whilealsobeingrelatively 112 HIV/AIDS 113 Added to this were arguments from some in global health Added to this were arguments the developing AIDS in treating world was leadership that Two neither cost-effective nor feasible for lack of infrastructure. on articles “data in The Lancet made this claim. One claimed that the cost-effectiveness of HIV prevention Africa in sub-Saharan and on highly active that indicate antiretroviral therapy prevention least 28 times more cost-effective is at than HAART.” The other argued: “The most cost-effective interventions are for of tuberculosis, and treatment while prevention of HIV/AIDS for adults, and home based care organized from health HAART and preventionTreatment facilities, are the least cost-effective.” the world in which many were deemed mutually exclusive. In kinds of stark these choices were thought to be operated, of House told the US the head of USAID Further, necessary. such incapable of taking Africans were generally Representatives, because, among other reasons, drugs even if they were available, of rendering time is their way Africans do not wear watches; different, and thus they would not be able to adhere to a schedule. treatment With the advent of these newWith the advent AIDS that drugs it was possible the thus altering disease, a chronic manageable could become But theycourse of the pandemic. were expensive—prohibitively so people. Theyfor many cost per year and $10,000 to $15,000 access would be critical. for life. Insuring needed to be taken mortality from AIDS-related States in the United Meanwhile, 1990s—between 1996 and 1997 in the late causes began dropping Thealone it fell 46 percent. domestic became less epidemic continued to be virtually pandemic and the international urgent, ignored. Where access has been greatest, mother-to-child transition transition mother-to-child been greatest, access has Where kept nevirapinewas Tragically, significantly. dropped have rates the 2002—when clinics until antenatal South Africa’s out of Constitutional Court intervened them available—because to make not cause AIDS. HIV did belief that of Thabo Mbeki’s Pandemics considered the lackluster USconsidered thelackluster responsetotheAIDSepidemic. 9. woulddisappear.cost-effective ofdrugsdropped,thenargumentsaboutthemnotbeing cost couldalso belowered.Andifthe bypeople,thenthey were set prices?ToWho sets theanswerwasthat ifhighprices activists What doesitmean tosay toomuch?Whodecides? thedrugscost andanswerstoaseries ofhardquestions: access toantiretrovirals generation emerged inSouthAfricaanddemanded ofactivists centeredonaccesstotreatment. Inactivism thelate 1990sanew Inconstructions. theearly1980s,ACTUPpioneeredAIDS global healthacceptedthisasfixedcosts rather thanhuman andARTtuberculosis Many expensive. wereextraordinarily in Forcost. muchofthe1990ssecond-linedrugsfordrug-resistant and Drugpolicy infundingandinterest? thisshift What explains for 2.5millionpeople. claimedthat theUnitedDepartment States wasprovidingART patients aroundtheworld;bySeptember2009State therapyantiretroviral (ART) hundred fornomorethanafew Foundation. For in2000theUnited example, States funded and majorphilanthropiessuchastheBillMelinda Gates Global healthbecameapriority fortheUnited States government waythe millenniumthereemerged anew ofseeingthepandemic. Beginningaroundtheturnof occurred. shift But thenatectonic During the1980s attention and1990s, ACTUPdrew towhat many 114 HIV/AIDS 115 The so Clinton supported going administration the drug makers, precursor to list”—the far as to put South Africa on a “watch Act would the Medicines sanctions—citing that the possibility Al Gore announced When Vice President rights.” patent “abrogate Claiming that the law violated their intellectual violated property rights, in Claiming the law that 1998 thirty-nine drug companies reacted by filing suit in South Action African court. Activists, the Treatment especially the costs of the drugs were far out of Campaign, argued that to say proportion to their research and development outlay, making them available. nothing of the humanitarian argument for Clearly, HAART could work in resource-poor settings. But drugs in resource-poor settings. could work HAART Clearly, drug and Brazil, India still cost a tremendous amount. In manufacturers versions of cheaper generic began to produce prevented But in the rest of the world patents commercial ARVs. forms, and pharmaceutical in generic drugs from being made Trade and the World States United companies, aided by the out of global circulation. generics to keep worked Organization, this by passing the to challenge 1997 South Africa attempted In Act, in the case of a public that which stipulated Medicines health emergency such as AIDS the country was allowed to both were stillproduce and import of drugs that versions generic patent-protected. Things began Research fronts. many happen on began to and suggestions of non-adherence the claims to counter appearing prevention exclusivewere mutually ends. Two that and treatment in 2001—one appeared studies out of HAART of the limited role Cape out of Khayelitsha, outside and the other of Haiti coming out the Cape In on treatment. people stayed demonstrated Town—that study scientists learned even the increase in more: with Town people sought testing. more and more That of treatment, availability there was effective and that more treatment, is, when people saw services.more sought out AIDS As more people knew their status, declined. transmission treatment, and more began to receive Pandemics George W.George Bush’s State ofthe Union Address.Bushsaid: (PEPFAR), announcedonJanuary 28,2003,duringPresident surprises—was thePresident’s PlanforAIDSRelief Emergency funders—as wellasoneofthebiggest funding. Andoneofthebiggest cameamassiveincreasein Alongside thechange indrugpolicy for cheapgenerics tofillthegapintreatment. doorwasnowopen drug companieshaddroppedtheirsuits.The ofgenerics.would allowimportation ByApril2001 allthirty-nine intopurchasingonlybrand namesand pressure any country the US course:theUnited government reversed States would not for Africa!”Protests broke andwithinthreemonths outelsewhere, behind himwithbannersthat read“Gore’s greedkills!AIDSdrugs forthepresidency,his candidacy suddenlyappeared protestors and helpless“African” AIDSvictims. image thepopularperceptionofdisease powerful contradicts This inJulylife-saving ofDurban,SouthAfrica, 2000. drugs inthestreets 10. years. lifemany drugscanextend Antiretroviral AIDS canbeprevented. Treatment Campaign demandfreeaccessto Action protestors . . . Seldom has history offeredagreater todoso opportunity Seldom hashistory 116 HIV/AIDS 117 To meet a severe abroad, crisis urgent and To . . . I ask the Congress to commit $15 billion over the next to commit $15 billion I ask the Congress five . . . for so many. much the Emergency I propose tonight Relief—aPlan for AIDS of work mercy beyond current all efforts international of help the people to Africa. to turn the tide new nearly $10 billion in years, including money, against AIDS in the most afflictedand the nations of Africa Caribbean. HIV/AIDS changed global health in fundamental ways: it global health in fundamental ways: changed HIV/AIDS and essential activist a vibrant changed that movement spawned which drugs are priced and accessed and also insisted in the ways on the link between health and human rights. The pandemic also we will nevermade it clear that of disease. live in a world free By the middle of the firstof the new decade century a combination lower of factors and treatment: the face of AIDS funding changed evidencedrug prices, growing of the efficacy in of treatment activism, grassroots and newresource-poor settings, funding uneven, access remains and However, sources such as PEPFAR. new to expand infections if the pandemic is mean access will have and lack of sources are fickle. Stigma to be stopped. Funding States, in the United understanding still hinder progress. Even where activism African and access has arguably been the greatest, DC, have Washington, American men and women in places like percent of far exceeding those of the white population—75 rates likewise, the black population; were among new cases in 2013 are black. During an percent of those living with HIV/AIDS 75 in Indiana drug users in rural outbreak of HIV among intravenous stigma was still clear that it became a major problem when 2015, some addicts refused to get tested, as they feared being labeled as if they from a local clinic; many were seen coming and going gay or know the consequences was available did not know treatment of sharing used needles. PEPFAR aimed to quickly scale up access to ARTs, modeled in scale up access to ARTs, aimed to quickly PEPFAR part after work being done in Uganda. Pandemics HIV/AIDS abletocombat onthoseleast it. rests clear. withtheotherpandemicdiseases,globalburdenof As of HIV/AIDS worldshouldmake thisvery isinthedeveloping amount that theoverwhelming andaccess—thefact opportunity It has alsoremindedusthat different weliveinaworldofstarkly 118 Epilogue

What are we to do with this history? Does all this past experience, all this history, inform the present? Yes and no. In spring 2015 the WHO released a statement admitting its lackluster response to the Ebola pandemic and calling attention to a number of “lessons learned.” It was a striking document. It was striking that in 2015 among the lessons learned were such things as the “lessons of community and culture.” That it took Ebola to show the value of local people and their knowledge is surprising. The WHO “learned the importance of capacity”—which means the WHO learned that the world did not have the capacity to handle epidemics. The WHO was “reminded that market-based systems do not deliver commodities for neglected diseases.” Why did it take Ebola to relearn that important fact? The WHO also learned that gains in such things as malaria control or women surviving childbirth can be reversed when “built on fragile health systems.” Is it truly possible that this lesson had not been learned before 2015?

I am not interested in indicting the WHO—it is in this instance an easy target—and it is commendable that the leadership is admitting mistakes. But the WHO is, for better or worse, representative of a way of seeing things in the world of global health, and the leadership’s statement on lessons learned allows me to make a point: every single lesson it learned (or in one instance relearned) could have been gleaned from a look at the

119 Pandemics responded toEbola whiletheworldwatched—be reliedonasfirst Without Borders—the groupthat soheroicallyandtirelessly In thefuture,willnongovernmental organizations like Doctors climate between change anddisease. connections of thehistoric period, wewoulddowelltopay moreattention tootherinstances andthearrival ofplagueinEuropethelateAsia medieval theperiodicriseintemperatures between incentralconnection habitat a forcholera. Andasmoreand moreresearchsuggests Risingwater temperatures north. mightprovidemore further possible that astemperatures Zikawillfindahome riseelsewhere, record highsandAedesaegyptifoundsuitablehabitat. It is 2016 AmericaandtheCaribbeanastemperatures inLatin set inearly mosquito—Zikaexploded toastheyellowfever referred the Zikavirus.CarriedbyAedesaegyptimosquito—commonly places.Take willinhabitnew mosquitoes,forexample, carrying likely that astheclimaterespond? It warms,disease- isvery climate futurepandemicsandourability change, to affect long ago challenges, willreemerge. like Buthowwill new global pandemics inthefuture?likely that patterns It isvery established made itsway intohumans,perhaps. How willtheworldconfront source—azoonosisthatinfluenza ormightemerge has fromanew A pandemicmightcomefromanoldandfamiliarfoesuchas Pandemics arenotgoing away. arenodoubtmoretocome. There butthereasonwhy mightbemore so. is important, weremade they are theoriginsofmistakes themselves? That ask:What WHO andothersmust The the mistakes ofthepast. culpas aretheenlightened onesfinallyseeing proffering themea the futurewillbedifferentandarroganttosupposethat those combination. It isnaivetothinkthat bysimplylearninglessons lethal and inefficient. Itisalsoarrogantandnaive—a wasteful It because Iamahistorian. isfrustratingjust becauseitis consciousnessisfrustrating,seems tobenohistorical butnot there pandemics hasbeenteachingthemforcenturies.That ofepidemicsand thehistory lessonsarenotnew; These past. 120 Epilogue 121 responders? Or will the WHO regain some of its lost stature? One One lost some of its regain will the WHO Or responders? stature? much of the pandemic a serious the face of is clear: in thing infrastructure health public will be woefully developing world’s will be that to ease the suffering One sure way overburdened. in building a is to invest future pandemic in any encountered robust public health infrastructure is lacking. The one anywhere are been and effects have and epidemic diseases of pandemic in the places least to be far worse Although able to respond. going simple common sense, it is clear from the this might seem to be “lessons learned” epidemic of the Ebola in the wake by the WHO is still it forgotten. routinely that

References

Introduction

For the pandemic criteria see David M. Morens, Gregory K. Folkers, and Anthony S. Fauci, “What Is a Pandemic?,” Journal of Infectious Diseases 200, no. 7 (2009): 1019–20.

Sanjoy Bhattacharya has written very effectively about the uses of history in contemporary discussions of epidemic disease: “International Health and the Limits of Its Global Influence: Bhutan and the Worldwide Smallpox Eradication Programme,” Medical History 57, no. 4 (2013): 486.

Chapter 1: Plague

The quotes on the experience of the first plague pandemic are from Lester K. Little, “Life and Afterlife of the First Plague Pandemic,” in Plague and the End of Antiquity: The Pandemic of 541–570, ed. Lester K. Little (Cambridge, UK: Cambridge University Press, 2007), 9.

For needing to employ such disciplines as zoology, archaeology, and molecular biology see Michael McCormick, “Rats, Communications, and Plague: Toward an Ecological History,” Journal of Interdisciplinary History 34, no. 1 (2003): 25.

On the first plague pandemic in Britain see J. R. Maddicott, “Plague in Seventh Century England,” Past and Present 156 (1997): 50.

123 Pandemics Cambridge University Press, 1993), 212,232. Epidemic Disease inNineteenth-CenturyIndia(Cambridge, UK: both inDavid StateMedicine Arnold,ColonizingtheBody: and Mahratta engineerare The quoteandthefromsanitary (New Haven, Yale CT: University Press, 2012), 185. Mark Harrison, Contagion:How Commerce Has Spread Disease isquoted in Epidemiological Society presidentoftheLondon The no. 3 (2002):737. Black Death: Endof a Paradigm,” AmericanHistoricalReview107, Cohn,“The On earlierplaguesnotbeingtheplagueseeSamuelK. Renaissance,” Medical History27, no.1(1983):31–32. An Explanation ofContagion andInfection From theGreeksto SeedsofDisease: values quoteisfoundinVivianNutton,The “The 1985), 39,27. Impact ofPlagueinTudor andStuartEngland(Oxford:Clarendon, andStephenBradwellRichard Leake arequotedinPaul Slack,The Disease inHuman History(Upper SaddleRiver, NJ: Pearson, 2007). quoteisfromJohn Ibnal-Khatib The TheFirstHorseman: Aberth, 94inHorrox, isdocument This BlackDeath,quoteon283. the royalmanorofDrakelow England,for1349–1350. inCheshire, Italian quotes.John deWodhull isquotedinthemanorialaccountof Jr. (Cambridge, MA:Harvard University Press, 1997);see48–49for Black DeathandtheTransformation oftheWest Cohn, , ed.SamuelK. Death,” Past andPresent 144 (1994):3–35,andDavid Herlihy, The respectively, John Hatcher, oftheBlack “EnglandintheAftermath inEnglandandItaly onlaborshortages arefrom, details The (1983): 511. the Italian Renaissance,” BulletinoftheHistoryMedicine 57, no. 4 On Venice in andFlorenceseeAnnG.Carmichael,“PlagueLegislation University Press, 1994),112,163,26–27. HorroxDeath, trans. anded.Rosemary (Manchester, UK:Manchester and the“French areallfromtheessentialvolumeTheBlack observer” quotesfromRalphofShrewsbury,The theParis theDecameron, masters, 124 References 125 Chapter 3: Malaria Chapter are Control in Panama and Mosquito The entomologist in Panama Isis of Empire?” or Agents Agents “Nature’s Sutter, S. quoted in Paul 744. 98, no. 4 (2007): 743, The Lewis and Clark is found in the online edition of The quote of Lewis and Clark Expedition, based on the edition of Journals http:// at available the journals by Gary E. Moulton, lewisandclarkjournals.unl.edu/index.html. One Vast Winter Count: The Winter Count: One Vast Calloway, is quoted in Colin Truteau of Lewis and Clark (Lincoln: University before American West Native 2003), 419. Press, Nebraska For the Huron calling the French the “greatest sorcerers on earth” see sorcerers on earth” the “greatest calling the French the Huron For and Travels Relations: The Jesuit Reuben Gold Thwaites, ed., , 1610–1791 France, Missionaries in New of the Jesuit Explorations 1640 (Cleveland:vol. 19, Quebec and Hurons: Burrows,, 1899), 91; Mentrak, by Tomasz this edition is a computerized transcription http://puffin.creighton.edu/ at available 2011, April 14, last updated jesuit/relations/relations_19.html. The Southeastern comes Epidemic Smallpox concept of the Great Biological Kelton, Epidemics and Enslavement: from Paul (Lincoln: University 1492–1715 Southeast, Catastrophe in the Native 2007). Press, of Nebraska The and Thomas the English colonists quotes from William Bradford The Rationalizing Epidemics: S. Jones, are from David Hariot since 1600 of American Indian Mortality and Uses Meanings 26. 2004), 37, Press, University MA: Harvard (Cambridge, The quote from the Florentine Codex is found in John Mack Farther Farther Mack The the Florentine Codex quote from John is found in History Interpretive A New West: The American Hine, and Robert V. 22–23. 2000), Press, University CT: Yale Haven, (New The Greatest Killer: The Greatest Killer: Chung Hopkins, in Donald R. is The from Ho quote 2002), 104. Of Chicago Press, (Chicago: in History Smallpox University Chapter 2: Smallpox 2: Chapter Pandemics Modernity,” Journal ofHistoricalSociology 7, no.3(1994):247. Imperial of 1832 andtheMorbid Cholera Ordure:The Resolutions of For thequotefrom theFrench writer seeVijay Prashad, “Native Dirt/ (New York: Oxford University Press, 2009), 56. Hamlin Hamlin,The quoteisinChristopher Cholera: TheBiography Chapter 4:Cholera Infectious Disease,” Science133,no.3458(April7, 1961):1058. Cockburn quoteisfromT.The AidanCockburn,“Eradication of Medicine 41,no.9(1966):S138. Bearing onMedical Countries,” Education intheDeveloping Academic McDermott isquotedinWalsh McDermott, “Environmental Factors World ofDiseasesForever? (Ithaca, NY: CornellUniversity Press, 2011), 155. Paul Stepan,Eradication: Riddingthe Russell isquotedinNancy Leys Hopkins University Press, 2007),96. of aTropical Disease: AShortHistoryofMalaria (Baltimore:Johns quoteisinRandallM.Packard, Brazilian newspaper The TheMaking Review 9,no.2(1972):142. Mortality inBengal, 1840–1921,” IndianEconomicandSocialHistory arequotedinIra andChristophers “MalariaBentley Klein, and Western Medicine, 194. Tropics’ to‘Tropical Diseases,’ the Invention ofMansonian Tropical Medicine: From ‘Diseasesin the Patrick Manson isquotedinMichael Worboys, Malaria “Germs, and ed. Mark Jackson (Oxford:OxfordUniversity Press, 2011), 89. Enlightenment,” inTheOxford Handbook oftheHistoryMedicine, James LindisquotedinE. C.Spary, “Health andMedicine inthe Rodopi, 1996),73. of Tropical Medicine, 1500–1900, ed.David Arnold(Amsterdam: Caribbean,” inWarm ClimatesandWestern Medicine: TheEmergence “Race, War, andTropical Medicine intheEighteenth-Century F.Collins isquotedinKenneth KipleandKriemhildConeèOrnelas, ” inArnold,Warm Climatesand 126 References 127 19, no. 4 (1919): 265, 268. of Nursing American Journal The Wilcocks quote on lesions is in Charles Wilcocks, “Tuberculosis in The Wilcocks quote on lesions is in Charles Wilcocks, “Tuberculosis the of Transactions and Subtropical Regions,” of Tropical the Natives , 32, no. 6 (1939): 681. and Hygiene Medicine Royal Society of Tropical Public Health Commissioner of Bombay quoted in Niels Brimnes, Commissioner of Bombay Health Public 48. possession), (unpublished manuscript in author’s “Languished Hopes” The Long quote is in Esmond Long, “Artificial Pneumothorax in Pneumothorax The Long quote is in Esmond Long, “Artificial Tuberculosis,” quote is in David S. Barnes, “Historical Perspectives on the Perspectives S. Barnes, “Historical The Times quote is in David Microbes and Infection 2, no. 4 (2000): 434. Etiology of Tuberculosis,” The Ransome quote is from Arthur J. Ransome, “Some Evidence Ransome, “Some Evidence The Ransome quote is from Arthur J. of the Transactions Areas,” Infective Respecting Tubercular 124. Epidemiological Society 7 (1886–87): The Address Wilcocks quote is from Charles Wilcocks, “Presidential Royal Sanitary Institute 73, and Industry in Africa,” on Tuberculosis no. 5 (1953): 481. The Cummins quote is from S. Lyle Cummins, “Tuberculosis and Cummins, “Tuberculosis The Cummins quote is from S. Lyle 141. 31 (1937): 140–43, of Tuberculosis British Journal the Empire,” Chapter 5: Tuberculosis Chapter Spitting Blood: The Bynum, are quoted in Helen and Engels Marx 112. 2012), Press, (Oxford: Oxford University History of Tuberculosis are quoted in Valeska in Valeska Times of India are quoted and the The delegate Italian International “TheThe by Disease? of the Globe Unification Huber, 49, Historical Journal SanitaryCholera, Conferences on 1851–1894,” no. 2 (2006): 464, 473. The quote from the Indian SanitaryThe is in Arnold, Commissioner the Indian quote from the BodyColonizing , 191. Medico-Chirurgical TheMedico-Chirurgical Review , the Quarterly from the quotes of The Return Durey, in Michael are all and The Lancet , Durey, Review Gill & (Dublin: 1831–32 the Cholera, Society and British the Plague: 136. 111–12, 111, 1979), 7, MacMillan, Pandemics Nigeria,” SocialScienceand Medicine 32,no.12(1991): 1395. and Physiological ResponsestotheInfluenza Pandemic of1918–19 in For being“upsidedown” Sierra Leone see DonC.Ohadike, “Diffusion of1918,”Flu’ Challenge SocialHistoryofMedicine 16,no. 1(2003):101. Triumphalism From andLearning Facts: andthe‘Spanish Bacteriology isinEugenia quotefromtheItalian Tognotti, doctor The “Scientific Bedford/St.Martin’s,(Boston: 2013), 64. The Influenza Pandemic of 1918–1919: ABriefHistorywithDocuments BritishMedicalThe Journal Kent, quoteisfoundinSusanKingsley Chapter 6:Influenza 375 (2010): 1906. TuberculosisAssociated Epidemic—When WillWe The Lancet Act?” HarriesThe quoteisinAnthony D. HIV- Harries al., et “The Tuberculosis andLungDisease, Paris, France. CARG(4)/94.4, ArchivesoftheInternational Union Against Agenda forCollaboration ofAIDSandTBProgrammes,” WHO/TB/ in “HIVandTuberculosis: Implications forTBControlStrategies and statement oftheWHOandInternationalThe Union canbefound Union againstTuberculosis andLungDisease62,no.4(1987): 9. Tuberculosis, andMycobacterioses,” BulletinoftheInternational HecatombThe quoteisfromJ. Prignot andJ. “AIDS, Sonnet, Tuberculosis andRespiratory DiseaseAssociation54,no. 10(1968):11. McDermott, “Tuberculosis at Home andAbroad,” BulletinoftheNational McDermottThe quoteonadvances inbiomedicineisWalsh author’s possession). Tuberculosis inIndia c.1920–1960,” (unpublishedmanuscriptin Frames:Cultural andBacteriological Approachesto Shifting WHOquoteonpossibilitiesisinNeil Social, The Brimnes,“Between National Archives. November 27, 1953,Press ReleaseWHO/70,MOH3/742, Kenya Tuberculosis,Against toMeet WHOExperts inCopenhagen,” isinWHO, WHOquoteonthelargest massaction The “Vaccination 128 References 129 13, no. 2 (1987): of Southern African Studies 13, no. 2 (1987): ” Journal Manchester Guardian, , the Manchester Journal Quotes from the British Medical of Expertise: “The Failure M. Tomkins, are in Sandra and Newsholme Influenza in Britain during the 1918–19 Policy Health Public 5, no. 3 (1992): 440, 444. Social History of Medicine Epidemic,” Quotes regarding Bloemfontein, South Africa, are in Howard are in Howard Quotes regarding Bloemfontein, South Africa, Phillips, “The Reform in South Health Local Public and State ‘Flu Africa: Bloemfontein and the Consequences of the Spanish Epidemic of 1918,’ 211, 218, 224. The quote from the native commissioner and the Native Department The commissioner and the Native quote from the native Pandemic in “The Influenza Ranger, in Rhodesia are in Terence Arnold, ed., David in Southern Rhodesia: A Crisis of Comprehension,” UK: Societies (Manchester, and Indigenous Imperial Medicine 178. 1988), 177, Press, University Manchester The quote on the pandemic being a “point of departure” is in Kent, , 111. Pandemic of 1918–1919 Influenza The quote on how we’re still unable to predict a pandemic is from The quote on how we’re and Folkers, Gregory K. Taubenberger, Jeffery K. M. Morens, David Clinical 500th Anniversary,” Influenza’s “Pandemic S. Fauci, Anthony 1444. Infectious Diseases 51, no. 12 (2010): The quote from the British agent regarding Tonga is in Sandra M. is in Sandra The Tonga regarding the British agent quote from Western Samoa,” in “The Epidemic of 1918–19 Influenza Tomkins, no. 2 (1992): 190. The of the goals History 27, of Pacific Journal Epidemic Commission, Samoan Epidemic commission are in Samoan Commission (Report of), of the General to Both Presented Houses Zealand: New of His Excellency (Wellington, Assembly by Command 1919), 7. Government Printer, S. Johnson P. A. S. Johnson low” being “ludicrously figure see Niall On Oakes’s of the Accounts: Global Mortality the “Updating Mueller, and Juergen History of Bulletin of the Pandemic,” Influenza ‘Spanish’ 1918–1920 108. 76, no. 1 (2002): Medicine The colonial official remarking on the Lobis is in David K. Patterson, Patterson, TheDavid on the remarking official colonial in Lobis is K. of Journal in the Coast,” Gold “The of 1918–19 Epidemic Influenza 491. no. 4 (1983): History 24, African Pandemics Review of theEvidence,”Review TheLancet359,no. 9318(2002):1638. of HIV/AIDSEffectiveness inAfrica:ASystematic Interventions Guinness,“Cost- Creese, Katherine Floyd,AnitaAlban,andLorna Africa,” and James HAART G.Kahn,“HIVPrevention before inSub-Saharan fromTheLancetareElliotMarseille, two articles The Paul B.Hofmann, Bank’s CureforDonorFatigue,” TheLancet342,no.8863(1993):63. from theWHOtoWorldOn theshift World Banksee“Editorial:The UNAIDS: TheFirstTen Years (2008),UNAIDS/07.20E/JC1262E, 7. UNAIDSThe quoteisinJoint United Nations Programme onHIV/AIDS, Epidemiologic Paradigm,” Science234(1986):955–63. M. Mann, James W. Curran, andPeter Piot,“AIDS inAfrica:An Project SIDA’s C.Quinn,Jonathan inThomas workwasdocumented Ohio University Press, 2006),68. Mahler isquotedinJohn Iliffe,TheAfricanAIDSEpidemic(Athens: of HIV Prevention,” TheLancet372,no.9637(2008):475–88. andChallenge History andChantawipaDavid Apisuk,“The Serwadda, For theslowglobalresponseseeMichael H.Merson, Jeffrey O’Malley, Chapter 7:HIV/AIDS Press, 2012), 159. Worlds ofthe1918 InfluenzaEpidemic(New York: OxfordUniversity Bristow,Rosenau isquotedinNancy K. AmericanPandemic: TheLost 49, no.4(2003):32. 1918–9 andIts Impact ontheBritishEmpire,” CaribbeanQuarterly Killingray, “A New ‘Imperial Disease’: Influenza The Pandemic of “So vast wasthecatastrophe” fromtheTimesisquotedinDavid Routledge, 2003),155. Perspectives, ed.Howard PhillipsandDavid Killingray (New York: Britain, 1918–19,” inTheSpanishInfluenzaof1918–19: New in NiallP. OvershadowedKiller:Influenza S. Johnson, in A. “The quotefromTheTimescomparinginfluenzatotheBlackDeath is The The Lancet359,no.9320(2002):1851–1856, 1851,andAndrew 130 References 131 For Bush’s remarks see George W. Bush, “Address before a Joint before a Joint Bush, “Address see George remarks W. Bush’s For 28, 2003,” January of the Union, Congress on the State Session of the Documents 39, no. 5 (2003), Compilation of Presidential in Weekly http://www.gpo.gov/fdsys/pkg/WCPD-2003-02-03/pdf/ at available WCPD-2003-02-03.pdf. South Africa abrogating “patent rights” is in Messac and Prabhu, and Prabhu, in Messac rights” is “patent Africa abrogating South 122. Possible,” “Redefining the

Further reading

General The most comprehensive overview of epidemic and pandemic disease (disease in general, really) is Kenneth Kiple, ed., The Cambridge World History of Human Disease (Cambridge, UK: Cambridge University Press, 1993). William McNeill’s Plagues and Peoples (New York: Anchor, 1998; originally published in 1976) is a classic. Particularly useful for writing this book have been Mark Harrison, Disease and the Modern World: 1500 to the Present Day (Oxford: Polity, 2004); J. N. Hays, The Burdens of Disease: Epidemics and Human Response in Western History, 2nd ed. (New Brunswick, NJ: Rutgers University Press, 2009); and Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: Norton, 1997). An excellent collection of essays, including a superb introduction on what historians might learn from epidemics and why they are so fascinated with them, is Terence Ranger and Paul Slack, eds., Epidemics and Ideas: Essays on the Historical Perception of Pestilence (Cambridge, UK: Cambridge University Press, 1992). An excellent discussion of the ways in which we might think about epidemics and pandemics historically is Charles E. Rosenberg, “What Is an Epidemic? AIDS in Historical Perspective,” Daedalus 118, no. 2 (1989): 1–17. For a guide to the literature on epidemics and pandemics generally see Christian W. McMillen, “Epidemic Diseases and Their Effects on History,” Oxford Bibliographies Online.

133 Pandemics well understood as its role elsewhere. See Nukhet Varlik, SeeNukhet asitsrole elsewhere. well understood Plagueand Medicine, plague’s 2008).The place intheOttoman Empireisnotas Medieval Wellcome Plague(London: Trust of CentrefortheHistory ontheplague:Pestilentialperspectives Complexities:Understanding edited byVivianNutton many brings together interdisciplinary (Oxford: OxfordUniversity Press, ofessays 2010). collection The Cultures ofPlague:Medical Thinking at theEndofRenaissance K. Cohn, flourishing ofmedicalwritingon theplagueseeSamuel theBlackDeath therearemany Onthe Beyond histories. excellent East (Princeton, NJ: Princeton University Press, 1977). On theMiddle seeMichael East Dols,TheBlackDeathintheMiddle 1346–1353: TheCompleteHistory(Woodbridge, UK:Boydell,2004). isOleJ.comprehensive history Benedictow, TheBlackDeath, Devastating PlagueofAllTime(New York: Harper, most 2006).The Mortality: AnIntimateHistoryoftheBlackDeath, theMost isJohnOn theBlackDeath overview aworthwhile Kelly, TheGreat University ofJordan, 1996). Byzantine Period, ed.Muhammad AdnanBakhit(Amman: Proceedings oftheSymposiumonBiladal-Shamduring Plague ofBiladal-ShaminPre-Islamic Times,”12–59, and“The in H SomeNew Insights SixthCentury: fromtheVersein theLate of thoroughly thananyone; seehis“EpidemicDiseasein Central Syria Conrad thepandemicinMiddle hasstudied more East (Cambridge, UK:Cambridge University Press, 2007).Lawrence I. Plague andtheEndofAntiquity:ThePandemic of541–750 ForK. Little, ed., Lester pandemicconsulttheessential thefirst et Mediterraneens, 2vols.(Paris: Mouton, 1975). Biraben, than what follows.Aclassic,onlyavailable inFrench, isJean-Nöel that readingslist ismorecomprehensive suggested series hasanexcellent University Press, 2012). Slack’s volumeintheVery Introduction Short see Paul Slack,Plague:AVery ShortIntroduction(New York: Oxford However, that coversallplaguepandemics introduction foranexcellent historiography. Much ofthat ontheBlackDeath. literature isfocused literatureThe onplagueisenormous—larger thanany otherpandemic Chapter 1:Plague ̣ assā ̄ n ibnTha Les Hommes etlaPeste enFrance etDanslesPays Europeens bit,” Byzantine and Greek Studies18,no.1(1994):Byzantine andGreek 134 Further reading

135 The literature on American Indians and disease generally is abundant. and disease generally on American Indians The literature on gone have Americas in 1491 of the The over the population debates Americana: Pox on Elizabeth Fenn, relied heavily for decades. I have Smallpox does not have nearly the same historiographical depth as the nearly the same historiographical does not have Smallpox relied I have excellent works that many plague. There are, however, The Greatest Killer: on. The only real overview is Donald R. Hopkins’s 2002). It Chicago of Press, Smallpox in History (Chicago: University for is indispensable and covers the development vaccination, of example, very well. Chapter 2: Smallpox Chapter For an overview of the pandemic in cities see Myron Echenberg, Echenberg, an overview of the pandemic in cities see Myron For of Bubonic Plague, 1894–1901 Impact The Global Urban Plague Ports: overview 2007). A good Press, of the University York New York: (New tried to cope with plague, among in which the global community ways in Economy,” “Plague and the Global Harrison, other issues, is Mark CT: Haven, Disease (New Spread Has Commerce his Contagion: How has been The in India plague 174–210. 2012), Press, University Yale the subject of a number of excellent articles See and chapters. and Epidemic “Plague Panic Chandavarkar, especially Rajnarayan and Slack, Epidemics and in Ranger 1896–1914,” in India, Politics in Arnold, “Plague: Assault on the Body,” Ideas, 203–40, and David and Epidemic Disease in his Colonizing the Body: State Medicine of California Press, Nineteenth-Century India (Berkeley: University 1993), 200–239. The third pandemic has also benefited from much historical excellent through of the pandemic as it made its way writing. On the origins and out of China see Carol Benedict, Bubonic Plague in Nineteenth- 1996). Press, University Century China (Stanford, CA: Stanford Empire in the Early Modern Mediterranean World: The Ottoman The Ottoman World: Mediterranean Modern in the Early Empire 2015), Press, University Cambridge York: (New 1347–1600 Experience, 1700–1850 Ottoman, dans l’Empire La Peste Panzac, and Daniel early modern the plague in 1985). For (Louvain: Éditions Peeters, of Plague in The Impact indispensable Slack’s Paul England see 1985). England (London: and Stuart & Kegan Paul, Routledge Tudor Plague in Seventeenth Reason, and the Faith, Carlo M. Cipolla’s is a model of historical Norton, 1979) York: (New Century Tuscany writing. Pandemics chapters concerning smallpox inPeter Baldwin,Contagionandthe For smallpox inEurope seeHopkins, Killer Greatest , butalsothe American History(New York: Penguin, 2011). no. 1(2000):45–62.Onthistheme seeMichael Willrich,Pox: An Vaccination England,” inVictorian SocialHistoryofMedicine 13, Well Brand Us:’ Working-Class toCompulsory Resistance smallpox vaccinationresisting see Nadja Durbach,“ disease.For ofstate growthandinfectious thehistory between (1999): 121–60 worksontheconnections arebothexcellent Redefining theBodyPolitic 1799–1868,” Past andPresent 163 Walker’s EarlyModern Japanese “The State andAinuVaccinations: Japan (Stanford,CA:StanfordUniversity Press, 2007)andBrett L. Vaccinators: Smallpox,Medical Knowledge, andtheOpeningof History ofMedicine 83,no.1(2009).AnnJannetta’s The Smallpox Vaccination, 1789–1900,” specialissue,Bulletinofthe Sanjoy Bhattacharya andNielsBrimnes,eds., “Reassessing For vaccination’s receptionaround theglobeseeessays foundin (Tucson: University ofArizonaPress, 2015). C. Swedlund,eds., BeyondGerms:Native DepopulationintheAmericas among otherthings.SeeCatherine M.Cameron,Paul Kelton,andAlan overland,andmalnutrition, competition suchaswarfare, factors demise. Instead, arguethat population they collapsewasduetomyriad Indian susceptibility todiseasewasthesolecauseoftheirdemographic 195–224. Historians nowgenerally thenotion that American reject 1560–1831,” Slaveof Africa:The Trade andtheTransmission ofSmallpox toBrazil, smallpox totheNew World seeDaurilAldenandJoseph C.Miller, “Out on theCanadianplainsandinGreat region.Onbringing Lakes 2013) howsmallpox causedethnogenesis doesasuperbjobexplaining the LossofAboriginalLife(Regina,SK:University ofReginaPress, Press, 2015). James Daschuk’s ClearingthePlains:Disease,Politics, and Fight AgainstSmallpox,1518–1824 (Norman: University ofOklahoma Nebraska Press, 2007)andCherokeeMedicine: AnIndigenous Nation’s Catastrophe intheNative Southeast,1492–1715 (Lincoln:University of smallpox: EpidemicsandEnslavement:Biological books that discuss Harvard University Press, 2004).Paul Keltonhaswritten two essential Uses ofAmericanIndianMortality since1600(Cambridge, MA: 2001), andDavid S.Jones, RationalizingEpidemics:Meanings and SmallpoxEpidemicof1775–82The Great (New York: Hill &Wang, Journal ofInterdisciplinary History18,no.2(1987): 136 ‘They Might As ‘They

Further reading

137 ‘The Tender Frame of Man’: Disease, Climate and Racial of Man’: Frame ‘The Tender Chapter 3: Malaria Chapter Disease: A Short History of a Tropical The Making Randall Packard’s 2007) and Press, University Hopkins (Baltimore: Johns of Malaria A Global History of Malaria Burden: Humanity’s Webb’s James and agriculture hand go labor, in which malaria, migrant On the ways on and Epidemic Malaria Workers “Migrant in hand, see Alan Jeeves, and in Alan Jeeves 1906–1948,” the South African Sugar Estates, Malaria’s arrival in and myriad effects on the New World is the subject New effects in and myriad on the arrival Malaria’s Curtin, articles. books and of many Among the best are Philip D. History and Atlantic,” Across the Tropical “Disease Exchange Philosophy of the Life Sciences 15, no. 3 (1993): 329–56; Mark “ Harrison, Bulletin of the 1760–1860,” Indies, West India and the Difference in R. McNeill, 70, no. 1 (1996): 69–93; and J. History of Medicine in the Greater Caribbean, Ecology and War Empires: Mosquito 2010). Press, University UK: Cambridge (Cambridge, 1620–1914 (New York: Cambridge University Press, 2009) are both essential 2009) are both essential Press, University Cambridge York: (New books. two based much of the chapter on these reading, and I have Thein Sanjoy are well covered the disease efforts eradicate to of The Control and Eradication Expunging Variola: Bhattacharya, Delhi: Orient Blackswan, 2006), (New Smallpox in India, 1947–1977 of Diseases Leysand Nancy Ridding the World Stepan, Eradication: The WHO 2011). Press, Cornell University NY: (Ithaca, Forever available chronicled its efforts volume, now in a massive and essential Arita, Isao Donald A. Henderson, Fenner, electronically: Frank Danilovich Ladnyi, Smallpox and Its Ivan and Zdeněk Ježek, 1988), available Organization, Health (Geneva:Eradication World http://apps.who.int/iris/bitstream/10665/39485/1/9241561106.pdf. at William H. Schneider’s overview in Africa during Colonial “Smallpox Schneider’s William H. 193–277 is excellent. History 53, no. 2 (2009): Medical Rule,” (Cambridge, UK: Cambridge University University Cambridge UK: (Cambridge, Europe, 1830–1930 State in important 1999). Also Arthur and G. Carmichael is Ann. Press, M Silverstein, before in Europe “Smallpox the Seventeenth Century: of the History of Medicine Journal or Benign Disease?” Virulent Killer 147–68. 42, no. 2 (1987): and Allied Sciences Pandemics chronicled inWilliam F. Bynum,“Policing Hearts ofDarkness: growthofmedicalinternationalism andcholera The arebest 1830–1910 (Oxford:OxfordUniversity Press, 1987). Evans, DeathinHamburg: SocietyandPolitics intheCholera Years, (Cambridge, UK:Cambridge University Press, 1995);andRichardJ. State; Frank M.Snowden,Naples intheTimeofCholera, 1884–1911 inmedicaltheory,developments areBaldwin,Contagionandthe century,nineteenth especiallythegrowthofmodernstate and guidestocholera excellent inEuropethe authoritative. Three (New York: OxfordUniversity Press, 2009).It iswide-ranging and I have reliedheavily Hamlin’s onChristopher Cholera: TheBiography 1821 and1867,” BulletinoftheHistoryMedicine 22(1948):562–93. H.Ackernecht, “Anticontagionism19 (1961):76–96,andErwin between Century,” intheNineteenth andSociety “Cholera Briggs, Past andPresent historiography diseasegenerally. ofcholera andinfectious areAsa They Two especiallyhave onthe articles hadanenormousimpact Chapter 4:Cholera eradicate generally andtheMalaria Eradication Campaignspecifically. a Tropical theimpulseto Diseaseareessentialforunderstanding (Ithaca, NY: CornellUniversity Press, 2011) andPackard’s TheMaking of Stepan’sNancy Leys Eradication: Ridding the World of Diseases Forever? Tropical Africa(Cambridge, UK:Cambridge University Press, 2014). ofJames Webb,subject A. L. Jr., TheLongStruggleagainstMalaria in associated withcontrollingmalariainAfricaarethe difficulties The the United States(Baltimore:Johns Hopkins University Press, 2001). Margaret Humphreys, Malaria: Poverty, Race,andPublicHealth in 1900–1962 (New Haven, Yale CT: University Press, 2006),and to doitiswelltoldinFrank Snowden,TheConquestofMalaria, Italy, ofa ofwaysvariety tocontrolmalariaandthedevelopment effort The 25, no.2(1984):189–212. Malaria EpidemicsinColonialSwaziland,” Journal ofAfricanHistory Packard, “Maize, Cattle andMosquitoes: Political The Economy of Africa: University ofNatal Press, 1997),114–36. SeealsoRandallM. Change inSouthernAfrica,1910–1950 South (Pietermaritzburg, Jonathan S.Crush,WhiteFarms, BlackLabor:TheStateandAgrarian 138

Further reading 139 The Cholera Years: The United States in 1832, 1849, and 1866 United The Years: The Cholera The Epidemic Streets: Infectious Disease and Infectious The Epidemic Streets: England: Ann Hardy, For (Oxford: Clarendon, 1856–1900 Medicine, the Rise of Preventive A Social History Mountain: Below the Magic 1993), and Linda Bryder, Britain (Oxford: Clarendon, in Twentieth-Century of Tuberculosis of a Social Disease: S. Barnes, The Making David France: 1988). For of (Berkeley: University France in Nineteenth-Century Tuberculosis Samuel K. States: Roberts, Jr., the United 1995). For California Press, On TB’s effectvariety of different places I on medicine and society in a On TB’s relied on the following: have Chapter 5: Tuberculosis Chapter Spitting Blood: A There are several overviews Bynum’s of TB. Helen is the 2012) Press, (Oxford: Oxford University History of Tuberculosis The Ryan’s Frank most recent and the one I turned to most frequently. Won—and Was the Battle against Tuberculosis Plague: How Forgotten The White Brown, 1994) and Thomas Dormandy’s Lost (Boston: Little, 1999) are also (London: Hambledon, Death: A History of Tuberculosis very valuable. (Chicago: University of Chicago Press, 1987; originally published in 1966). 1987; of Chicago Press, (Chicago: University Africa in the Time of Cholera: A History of Africa in the Time of Cholera: Echenberg’s Myron Pandemics UK: Cambridge (Cambridge, to the Present from 1817 see Charles States E. On the United is essential. 2011) Press, University Rosenberg, On cholera in India, David Arnold’s Colonizing the Body is the place Arnold’s David in India, On cholera to start. The Ghost Map: The The Ghost Map: overwroughtDespite the title, Steven Johnson’s Changed It How Epidemic—and Terrifying Most Story of London’s is Riverhead, 2006) York: (New World and the Modern Science, Cities, changing Snow and the of John account of the work a compelling transmission. ideas concerning disease History and History SanitaryAspects Conferences,” the International of and Valeska 421–34, 3 (1993): 15, no. Life Sciences of the Philosophy International “The The Disease? Globe by of the Unification Huber, 49, Journal Historical Sanitary on Cholera, Conferences 1851–1894,” 453–76. no. 2 (2006): Pandemics modern medicine. thehubrisof ofinfluenzawaslikeexperience aswelldiscussing University Press, 2012) jobchroniclingwhat doesanexcellent the Lost Worlds ofthe1918 InfluenzaEpidemic(New York: Oxford Bristol’s Nancy K. ofvirology; AmericanPandemic:the history The York: Penguin, andhasmuchon 2004)isespecially welldetailed Influenza: TheEpicStoryofthe Deadliest PlagueinHistory(New outside theUnited States aswell;John M.Barry’s TheGreat UK: Cambridge University Press, 1989),whichcoversregions Forgotten Pandemic: TheInfluenzaof1918, 2nded.(Cambridge, reading:AlfredW.States; allarewellworth Crosby, America’s ofthepandemicinUnited overviews areseveral things. There among otherorigins ofthepandemicaswellwhy itwassosevere, work. It hasalsospurredmuch biomedicalworkconcerningthe 1918–1919The pandemichasgenerated historical alotofexcellent (Totowa, NJ: Rowman&Littlefield, 1986). Pandemic Influenza, 1700–1900: AStudyinHistorical Methodology 1918–1919On influenzapandemicsbefore K. David see Patterson, Chapter 6:Influenza Global Poverty andthe“New” Tuberculosis Verso, (London: 2003). Matthew GandyandAlimuddinZumla,eds., ReturnoftheWhitePlague: TBpandemicis ofessays collection onthecontemporary An excellent Present (New Haven, Yale CT: University Press, 2015). my bookDiscoveringTuberculosis: AGlobalHistory,1900tothe vaccine, aswelltheTB/HIVpandemicandneoliberal thinking,see For tocontrolTBinternationally withantibioticsandtheBCG efforts University ofCaliforniaPress, 1989). Political EconomyofHealth andDiseaseinSouthAfrica(Berkeley: Randall Packard, WhitePlague,BlackLabor:Tuberculosis andthe American History(New York: BasicBooks,1994).For SouthAfrica: Shadow ofDeath:Tuberculosis andtheSocialExperienceofIllnessin (New York: Atheneum,1988);andSheilaM.Rothman,Livinginthe Caldwell, TheLastCrusade:War onConsumption,1862–1954 Hill:(Chapel University ofNorth CarolinaPress, 2009);Mark Infectious Fear: Politics, Disease,andtheHealth EffectsofSegregation 140 Further reading 141 27, no. 2 (1992): 181–97 tells the story 2 (1992): 181–97 no. History 27, of Pacific Journal (NewPerspectives New Pandemic of 1918–19: Influenza The Spanish Chapter 7: HIV/AIDS Chapter a is massive; not much of it is historical.The For AIDS literature A Very HIV/AIDS: introduction to the disease Alan Whiteside’s general Among the most accessible articles are in the biomedical literature “The Origin and Virulence of the 1918 ‘Spanish’ Taubenberger, Jeffery K. Proceedings of the American Philosophical Society 150, Virus,” Influenza A. A. H. Reid, T. K. Taubenberger, and J. no. 1 (2006): 86–112, Clinical Historical, and “Integrating G. Fanning, and T. Janczewski, GeneticMolecular of in Order to Explain the Origin and Virulence Data of the Philosophical Transactions Virus,” the 1918 Spanish Influenza 1829–39. (2001): Royal Society of London 356, no. 1416 The Monster at our Door: The Global Threat of Avian Flu Threat at our Door: The Global The Monster Davis’s Mike preparedness overview Owl, 2005) is a good of the world’s York: (New might give rise to a pandemic. and the conditions that The health policy place of flu in American life, science, and public is of Science and Public Influenza: A Century discussed in George Dehner, 2012). Press, of Pittsburgh University Response (Pittsburgh: Health The its effects especially pandemic, global Africa, Samoa, like in places subject also been the has and England, histories. of superb India, Iran, Killingray, and David Phillips overview an in Howard essays see the For eds., “The Mills, D. see I. 1918–1919 On India 2003). Routledge, York: and Indian Economic Indian Experience,” Pandemic: The Influenza effects in the pandemic’s For 1–40. Review 23, no. 1 (1986): Social History Constitutions: “Compromised The Iranian Amir Afkhami’s Iran, History of Bulletin of the Pandemic,” with 1918 Influenza Experience be consulted. The should pandemic no. 2 (2003): 367–92 77, Medicine Western islands, especially in Pacific had a devastating effect in the Western in “The of 1918–19 Epidemic Influenza Tomkins, Samoa. Sandra Samoa,” in Africa is the subject of wrath in all its gruesome detail. The pandemic’s a guide consult is cited in the references.a rich body of work; some For Local Versus “Global Explanations Falola, and Toyin Heaton Matthew Pandemic of of the Influenza The Historiography Interpretations: History in Africa 33 (2006): 205–30. in Africa,” 1918–19 Pandemics Mathew University Basilico(Berkeley: ofCaliforniaPress, 2013), Introduction, ed.Paul Farmer, Jim Yong and Kleinman, Kim,Arthur Global AIDSResponse,” inReimaginingGlobalHealth: An and Luke Messac andKrishnaPrabhu, the “Redefining The Possible: Between North andSouth(Ithaca, NY: CornellUniversity Press, 2012), relationship seeNitsanChorev, TheWorld Health Organization World To important. isvery Bank,andAIDS policy this understand role ofneoliberalism anditstransformationThe oftheWHO, the Press, 1999)isessentialreading. Epidemic: Cultural Chronicles ofAIDS (Durham, NC: Duke University Paula Treichler’s A. ofessays collection How toHave Theoryinan York: Free Press, 2004). Pandemic, Humanitarian theGreatest CatastropheofOurTime(New Invisible People: How theU.S. SleptThrough theGlobalAIDS ofthepandemiccanbefoundinGregBehrman,The neglect The University ofCaliforniaPress, 2005). Democracy: TheIndustrializedWorld Faces AIDS(Berkeley: EuropeconfrontedAIDS,seePeterwestern Baldwin,Diseaseand For lookat howtheUnited adetailed States andmany countriesin California Press, 1996). Activism, andthePolitics ofKnowledge University (Berkeley: of Impure ofStephenEpstein, Science:AIDS, more—are thesubject much movementandtheoriginsofcitizenscientists—and activist The traveled. whereAIDSlikelysingle volumeexplaining camefromandhowit AIDS (Cambridge, UK:Cambridge University Press, 2011) isthebest (Oxford: James Currey, 2006).WhileJacques Pepin’s TheOriginsof 2007), andJohn Iliffe,TheAfricanAIDSEpidemic:AHistory West, andtheFightagainstAIDS(New York: Farrar, Straus &Giroux, pandemic inAfricaseeHelen TheInvisibleCure: Epstein, Africa,The History ofAIDS(New York: Smithsonian,2006).To the understand canbefoundinJonathanoverview Engel, TheEpidemic:AGlobal Asolidhistorical placetostart. Short Introductionisanexcellent 142 Further reading 143 For the myriad ways in which AIDS has changed global health see which AIDS has changed in ways the myriad For England New Health,” Global AIDS Invented “How Allan M. Brandt, 2149–52. (2013): 368, no. 23 of Medicine Journal 111–32. This essay also covers the changes in thinking regarding access regarding in thinking the changes also covers This essay 111–32. costs and their to drugs activism. as AIDS as well

Index

Note: Page references in italic refer to illustrations.

AIDS. See acquired immune A deficiency syndrome acquired immune deficiency Alaska, 91 syndrome (AIDS), 58 American Indians. See Native activism, 114, 115–16, 117 Americans in Africa, 86, 103, 108–11, 113, 116 American Medical Association, 91 prior label of, 104 anopheline mosquitoes, 47, 49, stigma, 108 53, 54 ACT UP, 108, 114 antibiotics Africa, 90. See also slavery and malaria and, 55 slave trade; South Africa; West TB, 81, 82, 85, 88 Africa antigenic drift, 95 AIDS in, 86, 103, 108–11, 113, 116 antiretroviral drugs, 112 cholera in, 61–62, 71 antiretroviral therapy (ART), 114 HIV/AIDS as originating in, 103 artemisinin, 59 influenza impact in, 100 Asia, 51, 62, 82, 89, 90, 120 inoculation practice in, 37 plague outbreaks in, 30 plague and, 7, 30 as possible plague origin, 7, 10 TB and HIV/AIDS in, 86 Australia, 24, 89, 91 African Americans avian influenza, 94–95 racialized HIV/AIDS, 117 racialized TB and, 82 Africans, 5, 48, 108 B colonial doctors and, 96 Bacillus Calmette-Guérin (BCG), racialized HIV/AIDS and, 113 84–85. See also plague TB resistance in, 83 Bede, 8 agriculture, malaria and, 45–46, Bentley, C. A., 51 51–52 Biggs, Herman, 79

145 Pandemics cholera, 60–72 21,24,China, 31,37–38, 89,90, children, 40,78,82,112–13 Edwin,67–68Chadwick, Centers forDiseaseControl(CDC), The CausesofBlackwaterFever in Carson, Rachel,57 Canada, 39,82 Cambodia, 59 C Byzantine Empire,7–8 W.,Bush, George 116–17 Brown, Lawrason, 80 British Medical Journal, 89,97 Brazil, 49,52,55,57, 115 Bradwell, Stephen,19 Bradford, William,33,35 (Verdi),La Bohème 75 Boccaccio, Giovanni, 11–12 black SouthAfricans,5,48,52, Black Death, 4,10–18, 22,24, 89,97 Bills ofMortality, 74 types, 60,71 2010 pandemicof, 61 treatment of, 60 transmission routeof, 64–68,72 quarantine and,64–65,66 and,63 poverty plague and,23,25 origin of, 60–61,62–63 of, 49,67–69miasma theory East-West divideand,70–71 causing, ofbacterium discovery contagion, 67–69 classical, 60,71 cause andsymptomsof, 60 A. gambiaefrom,54 91, 105 103, 104 51 Chrostophers), the Duars(Bentley/ 82–83, 97 69–70 146 disease disability-adjusted lifeyears 46,51 deforestation, The Decameron(Boccaccio),11–12 deaths. Seespecificdiseases DDT, 54,55,57 DALYs. See disability-adjusted life D contagion. Seealso specificdiseases consumption, 74, 76 oftheTropics Conquest “The for communism, malariacontroland,54 colonization, 32–37, 48, 96,105 48 Collins, Robert, Cockburn, T. Aidan,55 Bill,115 Clinton, climate, 48,120 classical cholera (V. cholerae 01), William,36 Clark, S.R.,Christophers, 51 Chou-hou pei-tsifag(Prescriptions choleraphobia, 63 Cummins, Lyle, 76 culture cowpox variolaevaccinae Corriere dellaSera , 99 border), Cordon sanitaire (sanitary fear of, 4 eradicated, 41 miasma and,10–11, 19,40, ofideaof, 18–21 history plague and,10 TB and,75–76 intermsof,smallpox views 31–32 influenza and,100 (DALYs), 111–12 years the White Race” (Gorgas), 50 the WhiteRace”(Gorgas), 60, 71 for emergencies) (Ho 31 Chung), (smallpox ofthecow),38–39 65 67–69, 73 Index 18–19 disease (GRID), 104 also specific diseases 58 and Malaria, Tuberculosis, 109 89–90, 98, 104 inequality Climates in Hot to Europeans (Lind), 48 cholera in, 61 cholera contagion theory in modern, malarial stronghold in, 46 15, 22–23 13, 9–10, plague in, 8, in early modern, 37–40 smallpox 76, 77 TB in, 75, G 18, 19 17, Galen, 10–11, 42 Gandhi, Indira, 59 Foundation, Gates immunodeficiency gay-related disease and, 3. See geography, malaria and, 49 theory, germ for AIDS, Global Fund 119 global health, 117–18, 62, 63–64, 70, 117–18 globalization, on AIDS (GPA), Global Programme Gore, Al, 115–16 F 48, 59 falciparum malaria, 45, William, 67 Farr, of epidemics, 4 fear, 16 flagellants, 108 and Drug Administration, Food 19 Girolamo, Fracastoro, 65, 78, 2, 12, 16, 39, 64, France, 40 War, Franco-Prussian 41 freeze-dried vaccines, Inequality; Social Social See Inequality; equality. Incidental on the Diseases An Essay 50–51 Europe, 35–36, 8 Evagrius, 147 specific epidemics See also usefulness of, 59, 85, 88 usefulness of, 70–71 9 Ephesus), 7, 91 Jordan), (Oakes cholera in, 61, 65, 67 cholera influenza in, 97 99 in, deaths influenza-related 49 malaria in, 46, 47, 40 pandemic of 1870–1875, plague in, 8, 13, 15, 16, 20–23 in, 37–40 smallpox TB in, 76 1 common view of, 1–2 definitions of pandemics and, 4 fear of, virgin soil, 34, 91 geography and, 3 geography poverty and, 3 3–4 conditions and, social factorsusceptibility in, 4–5 antiretroviral, 112 resistance and declining Duesberg, Peter, 109 Duesberg, Peter, Dutch Reformed Church, 97 East India Company, 63 Company, East India and, divide, cholera East-West Ebola pandemic, 119, 120–21 Ecclesiastical History (Bede), 8 of Ecclesiastical History (John 71Echenberg, Myron, 58, 61, 71 economic inequality, 28, 31, 60 9, 16, 22–23, 24, Egypt, 7, 60, 71 biotype, El Tor 76 Friedrich, Engels, England Epidemic Diseases Act, 28 Epidemic Influenza: A Survey epidemics. Epidemics (Galen), 19 E doctors, colonial, 96 Doctors Without Borders, 120–21 drugs Gorgas, William, 50, 53 as retrovirus, 106 Gower, John, 14 spread of, 105–106 GPA. See Global Programme on stages, 106–107 AIDS as TB companion, 86, 87, 88 Grassi, Giovanni, 49 transmission, 105, 106, 109–10, Great Britain, 71, 81, 84, 85 112–13, 115 riots over cholera in 1832, 64 Ho Chung, 31, 32 World War I, influenza and, Hong Kong, 24, 94 98 Great Southeastern Smallpox Epidemic, 1696–1700, 35 I GRID. See gay-related Ibn al-Khatib, 18 immunodeficiency disease India BCG trials in south, 85 cholera in, 60, 61, 62–63, 69, 71 H influenza in, 91 H1N1 strain. See swine flu plague in, 21, 24, 28–30 H5N1 influenza, 94, 100, 101 smallpox in, 37, 42–44 HAART. See highly active TB in, 83, 85 antiretroviral therapy Indian Plague Commission, 29 Hariot, Thomas, 33 industrialization, 64, 76, 78 Harries, Anthony, 86 inequality. See also social inequality Harrison, Mark, 71 economic, 58, 61, 71 Health. See global health; Public influenza, 89–102 Pandemics Health Act avian, 94–95 Helms, Jesse, 107 culture and, 100 highly active antiretroviral therapy deaths caused by, 89–91, 92, 99 (HAART), 112, 113, 115 global estimate of mortality Hippocrates, 10–11, 17 from, 91 historical consciousness, 120 1918 pandemic of, 89, 93, 94, HIV/AIDS, 103–18. See also AIDS 100, 101, 102 animal origin of, 105 novel strain of, 94, 95, 100, antiretroviral drugs for, 112 101, 102 arrival in US of, 103 origin of, 89, 94 contagion of, 106 quarantine and, 92 deaths from, 104, 113 transmission of, 94–95 denialism and, 108–109 2009 pandemic of, 95, 100, genetic material of, 106 101, 102 geography and prevalence rate vaccines, 95, 101–102 of, 104, 105 virus types, 93–94 HIV virus types and subtypes, 105 Influenza Epidemic Commission, mother-child transmission 101 problem, 112–13 inoculation, smallpox, 37–38 racial factor, 117 International Sanitary Conferences, racial factor in treatment of, 113 27

148 International Union against Tuberculosis and Lung M Disease, 86 Mahler, Halfdan, 109, 110 Islamic Syria, plague in, 9 Mahratta, 29 Italy, 46, 53, 64, 71, 89 malaria, 45–59 malaria mosquito discovery in, agriculture and, 45–46, 51–52 49–50 anti-malarial resistance problem, plauge in, 14, 19, 22 59 communism and, 54 DDT and, 54, 55, 57 J geographical distribution and Japan, 25, 32, 39, 90, 104 conditions for, 47–48 Jenner, Edward, 38–39 mosquitoes, 45–47, 49, 52–54 Jews, Black Death and, 4, 12, 17 parasitic protozoan genus and John of Ephesus, 7, 9 types, 45 Johnson, James, 63 theories of, 48–49 Journal of the American Medical vector control of, 50, 52–54 Association, 50, 99 Malaria Eradication Program Justinian, Plague of, 7–8 (MEP), 55, 56, 57 Manchester Guardian, 97 K Mann, Jonathan, 109–10 Manson, Patrick, 50–51 Index Kaposi’s sarcoma, 103 Marx, Karl, 76 Kitasato, Shibasaburo, 25, 26 Mather, Cotton, 37–38 Knopf, Adolphus, 80 Mbeki, Thabo, 109, 113 Koch, Robert, 2, 69, 74, 78, 79 McDermott, Walsh, 54, 85–86 MDR-TB. See multi-drug-resistant (MDR) TB L Medical Research Council (MRC), labor, 76, 84, 97 British, 84, 95 migration, 52 Medicao-Chirurgical Review, 63 plague and, 13–15 Medicines Act, 115 laboratory revolution, 2–3, 25–26, MEP. See Malaria Eradication 74, 99 Program Laennec, René, 75 miasma, 5, 64–65 The Lancet, 65, 108, 111, 113 contagion and, 10–11, 19, 40, Laveran, Alphonse, 49 67–69, 73 Leake, Richard, 18–19 migration, malaria and, 49, 52. Lewis, Meriwether, 36 See also labor Lind, James, 48 mobility, population, 5–6 Liverpool School of Tropical modern state, 5 Medicine, 51 Montague, Mary Wortley, 38 London Epidemiological Society, mortality. See specific diseases 27 Morton, Richard, 74 Long, Esmond, 80–81 Mosquito Control in Panama, 47

149 mosquitoes Pasteur Institute, 104 malaria, 45–47, 49, 52–54 Pentecostal churches, 100 yellow fever, 120 PEPFAR. See President’s mother-child transmission, HIV/ Emergency Plan for AIDS AIDS, 112–13 Relief mourning wars, 35 Pettenkofer, Max von, 69–70 MRC. See Medical Research Pfeiffer, Johann Friedrich, 95 Council Phthisiologia (Morton), 74 multi-drug-resistant (MDR) TB, 88 Piot, Peter, 103 Mussolini, Benito, 53 plague, 7–28 of Athens, 31 bacillus, 25–26 N cause of, 7, 26–27 Nakajima, Hiroshi, 110 cholera and, 23, 25 National Cancer Institute, 104 climate and, 10 National Institute of Allergy and contagiousness, 18–21, 30, 35, 40 Infectious Diseases, 2 deaths caused by, 7–8, 12, 18 National Institutes of Health early explanations for, 10–12 (NIH), 2, 44 final years of, 22–23 Native Americans, 33–37, 80, 82, 84 global trade and, 24–25 Near East, plague in, 8 of Justinian, 7–8 nevirapine, 112–13 pattern, 17 Newsholme, Arthur, 98 population decimated by, 13 New Zealand, 82, 91, 92, 93, 100 premodern and modern, 26 Pandemics NIH. See National Institutes of quarantines imposed during, 21, Health 23, 24, 29 recent outbreaks of, 30 sanitation and, 12–13, 27 O state control and, 21–22 Oakes Jordan, Edwin, 91 symptoms, 26 On the Mode of Communication of tractatus, 17 Cholera (Snow), 68, 69 pneumothorax, artificial, 81 Ordinance of Labourers, 14 poverty, 63, 66–67, 77–78, 81–82 disease and, 3 P Practical Rules for the Management Panama Canal Zone, 47, 50 of Negro Slaves in the Sugar pandemics. See also specific diseases Colonies (Collins), 48 definitions of, 1–2 Prescriptions for emergencies future and, 120 (Chou-hou pei-tsi fag) historical themes surrounding, (Ho Kung), 31 2–6 President’s Emergency Plan for NIH criteria for, 2 AIDS Relief (PEPFAR), 116–17 persistent, 1, 3 Procopius, 7–8 Pasteur, Louis, 2 Project SIDA, 109

150 prostitutes, HIV/AIDS Science, 55 transmission to, 105 SEP. See Smallpox Eradication Public Health Act, 67 Program Public Health Service, US, 40, 99 Sierra Leone Weekly, 96 pulmonary tuberculosis, 73, 80 Silent Spring (Carson), 57 Simond, Paul-Louis, 25–26 slavery and slave trade, 5, 32, 35, Q 46, 47–48, 51 quarantine, 21, 23, 24, 29, 64–65, smallpox, 31–44 66, 92 cultural views of, 31–32 Quarterly Review, 63 decline prior to eradication, 42 quinine, 53 deities, 32 epidemic of 1696–1700, 35 inoculation, 37–38 R mortality decline, 39–40 race, 5, 24, 48–50, 82–83, 113, 117 pandemics, 36, 40 Ralph of Shrewsbury, 11 1700s change in, 37 Rand, W. C., 29 slave trade link with, 35 Ransome, Arthur, 78 stored vials of, 44 Reagan, Ronald, 111 vaccination, 38–44 reassortment, 95 WHO declaration on eradication resistance movement, against BCG of, 31 Index campaign, 85 Smallpox Eradication Program revolution. See laboratory (SEP), 41–44 revolution Snow, John, 68, 69 Rhazes, 31 social conditions, 3–4 Rhodesia. See Southern Rhodesia, social inequality, 61, 67, 72, 78 influenza pandemic in Soper, Fred, 54 riots, 29, 64 South Africa, 5, 24, 25, 82, 90, Rockefeller Foundation, 54 96–97, 100, 101 Roll Back Malaria, 58 nevirapine unavailability in, 113 Roman Empire, 8 South Africans, black, 5, 48, 52, Rosenau, Milton J., 99 82–83, 97 Ross, Ronald, 49 South Asia, 42, 45, 60, 87 Rules for Recovery from Pulmonary Southern Rhodesia, influenza Tuberculosis (Brown), 80 pandemic in, 96 Russell, Paul, 54 species sanitation, malaria control Russia, 9, 39, 40, 63, 65, 66, by, 53 78, 91 state control, 5, 21–22, 40 Statute of Labourers, 14 stigma, 4, 8, 108 S streptomycin, 82 safe-sex programs, 108 Sub-Saharan Africa, 86, 90 sanatoriums, 79–80 susceptibility, 4–5 sanitation, 12–13, 27, 53, 65, 69 Swaziland, 58

151 Swellengrebel, N. R., 53 race and, 5, 82 swine flu pandemic, 2009 types and mycobacterial family (H1N1 strain), 94, 95, 100, of, 73 101, 102 in underdeveloped world, 82–83 Sydenham, Thomas, 74 Tuberculosis as a Disease of the Syria, plague in, 9, 16 Masses and How to Combat It (Knopf), 80 T TB. See tuberculosis U Tennessee Valley Authority, 53 UNAIDS, 110 Third World, TB and introduction UNICEF, 55, 84 of term, 84 United States (US) Thucydides, 31 HIV/AIDS arrival in, 103 The Times, of London, 63, 79 HIV/AIDS response, 104, 105, Times of India, 70 106, 107–17 Tokugawa Shogunate, 39 influenza downplayed in, 99 trade, 24–25, 28, 35–36, 115. See Public Health Service, 40, 99 also slavery and slave trade sanatorium craze in, 79–80 Transactions of the epidemiological Smallpox Eradication Program Society (Ransome), 78 cost to, 42 A Treatise on the Small-Pox and United States International Measles (Rhazes), 31 Development Administration, Treatment Action Campaign, 54 Pandemics 115, 116 USAID, 113 Trincavella, Vetorre, 19 tropical medicine, 50–51 Trudeau, Edward, 80 V Truteau, Jean-Baptiste, 36 Vaccination Acts of 1885, 40 tuberculosis (TB), 73–88 vaccines and vaccination antibiotics and, 81, 82, 85, 88 BCG, 84–85 cause of, 73, 78–79 child deaths from, 40 culture and, 75–76 compulsory, 40 deadliest form of, 73 freeze-dried, 41 deaths from, 74, 75, 76, 81–82, 88 HIV/AIDs challenge for, 106 diagnosis of, 73–74 influenza, 95, 101–102 drug resistance, 85, 88 inoculation leading to, 38 geography of, 3, 87 Jenner’s discovery of, 38–39 HIV/AIDS companion of, 86, smallpox, 38–44 87, 88 success and spread of, 39–40 MDR-, 88 Valles, Francisco, 19 mortality rates of 19th-century variolation, 38–39, 40, 41 compared to present, 76 vector control, of malaria, 50, poverty and, 77–78, 81–82 52–54 pulmonary, 73, 80 Verdi, Giuseppe, 75

152 Villermé, René Louis, 67 HIV/AIDS response of, 86, 109, virgin soil epidemics, 34, 91 110, 111–12 virus, Zika, 120. See also HIV/ lessons and mistakes, 119–21 AIDS; Influenza malaria eradication agenda, 54–55, 56, 57 pandemic definition and, 2 W Smallpox Eradication Program, Waksman, Selman, 82 41–44 Watson, Malcolm, 53 TB and, 85, 86 West Africa, 32, 37–38, 52, World Trade Organization, 115 96–97, 105 World War I, 98 Western Samoa, influenza World War II, 82, 83, 100 pandemic in, 91–93 WHO. See World Health Organization Y Wilcocks, Charles, 76, 83 yellow fever mosquito, 120 World Bank, 58, 111 Yersin, Alexander, 25, 26 World Health Organization (WHO) BCG vaccination campaign of, 84–85 Z Ebola and, 119 Zambia, 58

eradication declaration by, 31 Zika virus, 120 Index

153