Alex de Waal begins his book by saying: ‘“War on disease” is not a harmless metaphor. It supresses critical thinking. It focuses our worries on a singular germ as our enemy, forgetting about other things – such as devastated ecologies and an inequitable society – that are no less pathogenic.’ He finishes by stating: ‘The time for the war on infectious disease has passed. It is a set of metaphors that have rotted away and become layers of sediment on the bed of the river. When we kick them up, we just muddy the water; we stop thinking critically at the critical moment.’
This is unfair to microbiologists. It takes them for granted. In 2016 I wrote in Have Bacteria Won? that microbiologists ‘sometimes use military metaphors in grant applications, and usually go along with them in press releases puffing their latest breakthroughs, but we don’t stand at our laboratory benches shouting “Let’s fight the captains of the men of death.”’Footnote 1 Fighting the ‘war on disease’ metaphor is to attack a straw man. It takes the work of scientists for granted. Their development of fingerprinting methods to identify microbial villains is not an impediment to ‘critical thinking’; neither is it a ‘harmful error’ to do fieldwork in hospitals to control MRSA or in abattoirs to prevent food poisoning or in rain forests to understand arbovirus ecology. It is not an error to be a brilliant naturalist like the entomologist Arthur Bacot, who showed why fleas are so good at transmitting plague and then studied the ecology of typhus, which killed him. And de Waal’s denigration of Robert Koch – who laid the foundations of bacteriology, discovered the pathogens that cause anthrax, tuberculosis and cholera, and initiated the evolution of ‘military-style public health’ measures – should not stand. The issues are far more complicated. De Waal uses the cholera outbreak in Hamburg in 1892 to support his views about Koch and the victory of imperial controls. But compare Hamburg to Glasgow, the first big industrial city. Overcrowding and health inequalities abounded. Night soil was collected in its tenements for sale. But their inhabitants escaped cholera a quarter of a century before Hamburg, not because of any public health measures, but because Glasgow had built aqueducts from a highland loch to bring clean water to help trade, supply its burgeoning population, and feed the ever increasing number of fire hydrants.
Books about pandemics must also discuss influenza in 1918–19. Official accounts of the pandemic by the Ministry of Health in London and the Medical Department of the US Army do not mince words. I prefer them to the secondary sources referenced in de Waal’s book, and disagree with the conclusion that the pandemic virus may have evolved in the German trenches. A mortality rate of over 100 per cent in German soldiers on the Western Front in July 1918, killing over 374,000 (p. 85), cannot be right. The German official medical history of the war lists 1,531,048 killed in battle and 155,013 dead from disease.
I do not subscribe to the view that ‘viruses don’t readily submit to our taxonomies’ (p. 226). It is unfair to June Almeida, the discoverer of human coronaviruses. For her, there was nothing indeterminate about the shape of the spike protein, the coronavirus identifier and generator of the name. And it is unfair to the scientists who have developed and used the techniques of molecular biology to identify and taxonomically situate SARS-CoV-2, detect variants, design PCR tests, and develop vaccines, all with unprecedented speed – biomedical science at its best. However, de Waal sees faith in vaccines as misplaced. Vaccines against diphtheria, measles, whooping cough, hepatitis B and rinderpest get no mention, and ones against polio and smallpox are categorized as generators of hubris.
The notion that virulent pathogens are created by ecological, social and health pathologies runs through the book. Pathogens can be helped to spread by these forces, but created? Evidence, please. I favour evolution via mutation, a random process. Has the evolution of influenza been speeded up by the factory farming of chickens? Evidence, please. My opinion is that protein from cheap poultry meat has played a bigger role in transforming tuberculosis into an asymptomatic infection (like the one I had) than any other measure. Is microbial mutation and zoonotic spillover increasing, and is ecological devastation increasing the frequency of pandemics? Evidence, please.
The ‘people’s science’ response to diseases may help. The ‘wisdom of whores’ (as Elizabeth Pisani puts it) may be epidemiologically interesting, but biomedical science developed the drugs that prevent death from syphilis and HIV. I am sceptical about the importance of public views of disease after reporting on outbreaks of infections caused by E.coli O157. A new variant that probably evolved in cattle on the Argentinian pampas, it spread worldwide, harmless in its ruminant hosts but causing serious, untreatable disease in humans. The most lethal UK outbreak was caused by a criminally incompetent butcher who had been voted ‘Scottish butcher of the year’ by his customers.
This well-written and provocative text seems heavily influenced by the author’s work on HIV and AIDS. But all pandemics, including Covid-19, are unique. The only certainty is that predictions about the timing and cause of the next one will be wrong. Viruses do not read our plans. The 2009 UK government flu plan predicted that a high-mortality virus would evolve in birds and arrive from China in weeks, but the virus was low-mortality, from Mexican pigs, and arrived in days. We have to do better. Is ‘emancipatory public health’ the answer? How will it prevent pathogen emergence and transmission? Daniel Defoe’s biographer Walter Wilson described his A Journal of the Plague Year as ‘written with rich natural pathos and exquisite moral feeling [with] attention riveted by the constant succession of incidents that crowd upon the scene’. An excellent description of de Waal’s book.
