This is a most important book. It skilfully reviews the history and politics of several pandemic diseases (including cholera, influenza, HIV and AIDS, and Covid-19). Each pathogen has a distinct and evolving character and presents itself to human understanding through a dense mesh of cognitive screens and filters – political, emotional, social and religious. Alex de Waal does a brilliant job of summarizing this complexity across 200 years or more of the ‘war on disease’. The importance of the book, however, lies in raising the issue of alternatives to ‘war’. Responses to pandemic challenges cannot be left to science but require activist ownership of human public health.
De Waal was involved in the HIV and AIDS policy response in Africa. His fear was that HIV and AIDS would destroy African society, both its economic systems and its social fabric. This didn’t happen, but the question is why. Therapy prolonged life. Risks were reduced through behavioural change. Loss of human capital proved to be less than expected. With ‘top’ social echelons thinned out by disease, new people stepped up to take their place. Activism shaped new social roles, thanks in large part to the positive influence of HIV-positive women. Institutions proved resilient.
De Waal distinguishes between two senses of the word ‘institution’: an organization (e.g. the World Bank or the Sokoto Caliphate) and, alternatively, a set of rules (p. 150). He endorses the late Douglass North’s description of institutions in the second sense as ‘humanly devised constraints that structure political, economic and social interaction’ – ‘norm institutions’ for short. Policymakers, according to de Waal, often believe that norm institutions ought to resemble ‘formal legal-rational bureaucracies’. Here, a touch of conceptual muddle is apparent. North himself divided ‘norm institutions’ into two classes, informal and formal, and claims (quite problematically) that the process of development involves the replacement over time of informal with formal arrangements. An economic historian, North promoted modernization theory by another name.
De Waal might have done better to refer to a rival conception of ‘norm institutions’ advocated (separately) by Oliver Williamson and Mary Douglas. In this second perspective, the human social world is – and always has been – a mixture of differently configured norm institutions. Attention needs to be focused on what happens at institutional boundaries. Both Williamson and Douglas recognize the problem as one of a ‘clash of institutions’. Williamson proposes to solve these through the device of transaction costs (those incurred in crossing a boundary between different institutional regimes). Douglas suggests that this will not do, since it grants the market a superordinating role. Better, she argues, to conceive of a level playing field, comprising a limited number of coexistent organizational forms, and to describe (ethnographically) what mutual accommodation between them is possible.
It is worth stressing that this is more than a quibble over terminology. How institutions are understood and defined greatly affects the scope for progress in terms of recognizing and working with forms of activism that de Waal later promotes as a pathway towards better pandemic responses, particularly to threats such as Covid-19.
This brings the problem of clashing institutions into focus. The concept of a ‘people’s science’, endorsed by de Waal (p. 206), makes little sense if cast within the constraining frameworks of market-based medicine articulated with hierarchically organized science. But as Douglas would have been the first to argue, it makes no sense on its own either, as a set of quaint practices carried out by isolates in a corner or by enthusiasts clinging together in a sect, impervious to the wider world.
De Waal understands that ‘the ecology of the Anthropocene and the social and economic organization of our human population are intrinsically pathogenic’ (p. 183). So, faced with a world of disease hazards we have all helped to create, he proposes that our best hope may lie with activist engagement of the kind apparent in the HIV and AIDS response, where those most affected by the problem became adept at pushing both science and politics towards sustainable solutions.
Here, his argument is less than complete. The book is good at showing how populist forms of politics tend to compound pandemic challenges. Cutting aid budgets and failing to distribute vaccines to all the world may one day be recognized as among the more serious mistakes of the Covid-19 response. Where the book is less strong, however, is in offering answers to problems of conflicted institutions.
A key problem is that some norm institutions engaged in pandemic response may be unfit for purpose. A high degree of integration between hierarchies of science and market institutions – the result, for example, of having a government scientific adviser with a background in private-sector pharmaceutical research – would be seen as a textbook example of the Williamson approach, effectively reducing transaction costs by coordinating policy demand and research supply. At the same time, it would ignore the extent to which so many key actors of disease transmission live outside such frameworks and are motivated by other existential concerns. Vaccine denial is not necessarily a product of ignorance. It is as likely a product of institutional exclusion.
A key part of the problem is how to rebuild science as a more globally inclusive norm institution. Terms such as ‘activism’ and ‘people’s science’ signal a potentially productive intention. But the journey itself, as Mary Douglas suggested in a late polemic aimed at a World Bank audience,Footnote 1 requires serious commitment to accommodation between competing institutional forms.
The problem to be resolved is institutional conflict itself. This is apparent in defective and ill-regulated reward systems sending out grossly misleading signals about what knowledge is important and what can be safely ignored, thereby distorting basic understandings of disease challenges. At the end, Alex de Waal excuses himself: ‘the policies and practices needed range far beyond the scope of this book’ (p. 230). Therefore, we must be patient and await the sequel, which promises to be as compelling reading as the present potent offering.
