The oscillations and tensions between public health and individual compassion animate Priscilla Wald’s Contagious: Cultures, carriers, and the outbreak narrative, a problematic but insightful narrative history of the American public health movement and its discursive systems that, as she amply demonstrates, attempt to transmute the suffering and ill-health of others into a detective plot. While these detective stories ‘derive their authority from their predictability and, in turn, establish the scientific validity of the approach they describe’, the strategies of disease containment and management transform, mutating from a concern for sick individuals into a mania for the maintenance of healthy populations (p. 25). Wald’s book provides a larger history for a contemporary manifestation of Foucault’s notion of ‘bio-power’ and the related obsession with controlling the health of the population that underlies some conceptions of the modern nation-state.

Using SARS as a starting point, the author traces the features of scientific and journalistic accounts of disease outbreaks, especially emerging diseases (bird flu, SARS, hemorrhagic fevers, etc.). Wald attempts to highlight the importance of these outbreak narratives to our contemporary understanding of global health. The contemporary outbreak narrates a formula for any response to ‘outbreak’: first identifying the source, then finding a healthy human carrier—i. e. ‘an apparently healthy person [who] could transmit a communicable disease’ (p. 68)—and finally creating a cure has, under the present configuration of global capital, turned into a concern over contact between zones of the globe coded as ‘primitive’ and those coded as ‘developed’. The author, a Professor of English at Duke University, summons the images of Chinese farmers living close to their animals that were offered as an explanation of SARS, and the murky and highly rumorological origins of AIDS in Africa, in illustrating the contemporary operation of this trend. Wald rightly worries that this primitive/developed narrative split transforms the abject poverty of global inequality into the inability of developing nations to rid themselves of outdated, anti-modern notions. In other words, the outbreak narrative allows the global North to ignore the glaring disparity with the global South by transforming poverty into a failure to fully participate in modernity. By revealing these trends, Wald’s book seeks to document ‘how the conventions of the outbreak narrative shape attitudes toward disease emergence and social transformation can lead to more effective, just, and compassionate responses both to a changing world and to the problems of global health and human welfare’ (p. 3).

Unfortunately, the account she offers largely fails to flesh out this more compassionate response to global health. Instead, the majority of the book presents an indictment of American epidemiological protocols in order to show how they fail to respond to the global nature of health management—a failure that Wald largely assumes as a given in the introduction. The first chapter, devoted to 1990s manifestations of the outbreak narrative in works such as The hot zone or the film Outbreak, shows how the public health protocols for dealing with emerging diseases depend on an imagined sense of nationhood and, more importantly, a perception of this nation as a body that is defensible. At the same time that these operations of national construction occur, however, the diseases that threaten the national body (and the nation’s bodies) manifest the global networks of capital that are dissolving the framework of these nation-states (think of how many journalistic accounts of SARS discussed the role of air transit in the disease’s spread, for example). As Wald writes, the tension lies in the fact that ‘epidemiologists map the imagined community of the global village, charting diseases as they cross national borders’ at the same time that ‘the depiction, as much as the management, of those diseases reinforces the boundaries’ (p. 67). The tension between individual and population (which Wald established as her main thesis) now seems more complicated, amplified into a narrative form that establishes a tension between yet another narrative—nation—and globe.

At the end of this first chapter, Wald seems poised to discuss how to reinsert the particular experience of illness into the narrative of global disease outbreak. Instead, and rather curiously, she chooses to historicize the outbreak narrative through an exploration of twentieth-century American public policy discourse. Rather than explaining the possibility of manifesting a global response and compassion for the individual sufferers of disease and the conditions of abject poverty that produce these sicknesses, Wald offers painstaking accounts of the origins of the various tropes of the current outbreak narrative. First, she explores the construction of the healthy human carrier by tracing the narrative conventions that surround the concern over Typhoid Mary in early twentieth-century America. In this account, she finds, once again, the connections between nations and diseases by showing that the desired behavior of healthy human carriers by early public health proponents mirrors rhetoric applied to the need for assimilation of immigrants at the time. Similarly, Wald offers accounts of the interpenetration of nations and diseases in the following chapters, which deal with public health attempts to deal with ethnic ghettos and with microbial warfare during the Cold War (discussing the parallels between plagues infiltrating the bodies of Americans and Communist agents infiltrating the national body). Strangely, for a book concerned with the global nature of contemporary disease practice, Wald only moves beyond the American nation in her last chapter, on the AIDS pandemic.

In this useful chapter, she shows how the narrative that we see operating in the first chapter and constructed in succeeding chapters, actually assisted in the spread of AIDS because this virus and its spread doesn’t map onto the traditional arc of the outbreak narrative. Ultimately, Wald concludes the book where she began: by showing how the outbreak narrative functions to exclude social factors in the production and the spread of disease, as well as to occlude the suffering of individuals. One would expect, perhaps, finally to get a possible map of this more compassionate approach to global health in the conclusion, but instead we come to the end of the book and find a chapter entitled ‘Epilogue’. While this may seem like the same thing, two of the definitions of the term ‘epilogue’ in the Oxford English Dictionary suggest that the term more generally refers to ‘an appendix’ or ‘a speech or short poem addressed to the spectators by one of the actors after the conclusion of the play’, in both cases suggesting that, in calling this last and brief chapter ‘Epilogue’, Wald is suggesting that the meat of the argument has already been presented, and that in recapitulating the initial claim, the work of the text is concluded with the end of the chapter on AIDS: in short, that what comes after is merely an afterthought.

In this epilogue, Wald offers a tentative sketch of the more compassionate approach to global health suggested in the introduction. In telling the story of the Cange, an impoverished region of Haiti, Wald shows how a view of health that encompasses the material conditions that are often the proximate or ultimate cause of disease (loss of income, malnutrition, corrupt governmental policies) can make a difference in the spread of emergent diseases in a way that is not driven by rhetoric of the global North being invaded and depleted by microbial forces from the global South (‘thirdworldification’ is apparently the term used in the discourse). Instead of expanding on these claims, she once again chides epidemiologists for falling back on a position that privileges modernity over and above the primitive Others of the developing world, even when these more social and progressive approaches to disease are often more effective.

Oddly, at the same time that Wald once again reacts to the violent and paranoid logic of the outbreak narrative, she affirms that global disease is a ‘species war’ that ‘threatens apocalypse’, which evokes the rhetoric of national defense that lies at the core of the outbreak narrative Wald is arguing against (p. 268). This militaristic language illustrates that ‘the stories and the world they imagine’ that get circulated by the outbreak narrative are more pernicious than Wald may like to imagine, given that her own concluding remarks are infected with this ‘us’ versus ‘them’ rhetoric. This slippage into the problematic language is why the conclusion to Contagious is so unsatisfying: Wald’s call for a more compassionate health system takes the form of helping the poor and changing narratives. While these may seem like simple tasks, the continued history of the activist Left suggests otherwise. To change a discourse: this is an incredibly arduous task that seems to suggest the need to shake society to its core. Ultimately, the problem identified in Contagious lies in the reaction of the nation-state to globalized networks of contact and exchange, which is no small problem. As such, what function does Contagious serve? While Wald lays out the problems with the current outbreak narrative, there is nothing in her history that suggests why these narratives came into being, so that this concluding call to change narratives of global health feels empty.

That said, one of the implicit—and quite fascinating—elements of Wald’s arguments is the growing sense of change that underscores the fabric of this text. Wald’s repeated claim that the outbreak narrative fails to function in the post-national, global context of contemporary disease is interesting, but I question if that is truly what is going on in the discourse she studies. Even the earlier, America-centered accounts she offers hinge on global networks of capital and the contact of distant populations. For that matter, the bubonic plague in Europe most likely entered the continent through a Genoese trading post on the Black Sea. Thus, it could be argued that, disease has always been a product of global capital. If that is the case, why does the argument—that nationalistic disease response (quarantine, ‘us’ versus ‘them’ rhetoric) no longer works—materialize at this moment? One could argue that earlier epidemics could just as easily highlight the dissolution of the nation-state. Part of the interest in Wald’s research has to lie in the moments where she, I think unintentionally, uncovers an emerging global consciousness (or, at least, a global awareness). She writes that: ‘the routes traveled by communicable disease light up the social interactions—the spaces and encounters, the practices and beliefs—of a changing world’ (p. 9). At another point in the work, she discusses the way that a visualization of disease transmission actually manifests, for viewers, the high degree of connectedness present in the contemporary, global economy. Part of the issue with her conclusions, though, is this rhetoric of ‘the changing world’. While I agree that this question of visualization, of lighting up social interactions, is an important issue, the history of disease being spread by the networks of capitalism renders the idea of a changing world problematic. Instead, it could be argued that what has changed is our ability to visualize these networks in a more effective manner. In this regard, what has changed is not the world but ourselves and our perceptions, and it is on those new perceptions that we must act.

Sadly, this change in global awareness is not addressed in Wald’s book. Instead, the rhetoric of ‘the changing world’ is substituted, which seems increasingly empty as a signifier. In any case, whether what she observes is the result in a shifting awareness of the global nature of humanity and consciousness, or whether the rules of capital are in some way changing, Wald’s account of the outbreak is definitely tapped into the potential for change inherent in the present moment. One of her concluding thoughts suggests that ‘the emerging stories can exacerbate or begin to change the inequities’ (p. 270) of the global, human condition. Although crafting these new, emerging stories about the world, about our place in it, and about the future of humanity may not be as easy as Wald’s conclusion would suggest, we live in an era in which attention to global matters is increasing and in which, as she rightly observes, the old rules and old stories no longer function. The possibilities for re-writing the script, not only of global health but also global humanity, along terms that deny ‘population’ and enhance individuals and communities, seem to be undoubtedly at hand. In raising these possibilities through a carefully crafted account of the construction of previous narratives of disease, Contagious raises important issues about the future of science and policy in this new era of global awareness. It serves as an interesting catalyst to further thought and, hopefully, action.