“Well, You’ve Just Scared the Sh*t Out of Me.” – A Review of Pandemic: Tracking Contagions, From Cholera to Ebola and Beyond by Sonia Shah

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I have been hospitalised thrice: twice for dengue, and once for typhoid. These events occurred about a year or two years apart, and all of them happened when I was in grade school. The first incident (dengue) happened when I was around eight or so, and the experience has left me with a deeply-ingrained, almost visceral, fear of hypodermic needles of any sort. This meant, of course, that the subsequent hospitalisation incidents were horrifying to me even if I was being treated at very good hospitals and received quality care every time.

And yet, despite the traumatising circumstances I have just mentioned, I am utterly fascinated by both diseases – especially dengue, which, unlike typhoid, cannot be vaccinated against and, being viral in nature, cannot be cured with antibiotics. Some might call it masochism, but I call it curiosity, more so because either disease could have killed me had I not received appropriate treatment and care before either disease could reach their more devastating stages.

This fascination extends to other diseases, like SARS and AIDS and Ebola: all of which are lethal, and all the more interesting to me because of that lethality. When news of the Ebola epidemic in West Africa made headlines in 2014, I kept an eye on it not because I was afraid the disease would make it to the Philippines, but because I was interested in learning about how such a deadly virus would spread, and more importantly, how it would be contained. I was also interested in the hysteria citizens of Western countries exhibited as the epidemic was ongoing, watching as the hysteria unearthed deep-seated racism and xenophobia even in more “enlightened” countries. The social aspect is as important and interesting to me as the medical side of things: after all, crises as large as the Ebola epidemic affect much more than just the bodies of the sick, but extend into the rest of society as well.

I am doing the same thing this year, now that there is nothing but talk of the Zika virus in the international news. While Zika is not as graphic in its effects as Ebola, there are still some interesting overlaps in terms of how people have reacted to it (in particular, how the Western – specifically American – scientific establishment did not really attempt to formulate a vaccine for it until it appeared within their own borders, much like how there was no serious attempt to create a vaccine for Ebola until American aid workers started coming home sick with it). Similar, too, is the hysteria some Americans are exhibiting over the virus, with several conspiracy theories regarding its origins already making the rounds.

In the end, it was Zika that led me to Sonia Shah’s book Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond. Shah did an interview with NPR about the future of pandemics, and it encouraged me to pick up her book.

Pandemic is divided into ten chapters, plus an introduction. In each chapter, Shah tells the story of the 19th century cholera pandemic that brought several major European and American cities to their knees with her own investigation into the nature of 21st century pandemics. From time to time, her narrative is interspersed with her own personal experience, ranging from recollections of visiting family in India to helping her son recover from a wound infected with MRSA (methicillin-resistant Staphylococcus aureus: the poster child of drug-resistant bacteria). The goal is to understand how and why pandemics happen, and what humanity can do to stop them – or if not, at least mitigate their spread.

The first thing the reader needs to realise about this book is that it is not for the squeamish, nor for the hypochondriacal. Shah does not hold back in describing the effects of some of the deadliest pandemics in the world; indeed, she opens her Introduction with the following excerpt:

Cholera kills people fast. There’s no drawn-out sequence of progressive debility. The newly infected person feels fine at first. Then half a day passes ,and cholera has drained his or her body of its fluids, leaving a withered blue corpse.

That’s why, even after being infected, you could, say, eat a decent breakfast at your hotel, of sunny-side-up eggs and tepid juice. You could drive over dusty, potholed roads to the airport. You’d feel perfectly well enough to withstand the long queues there. Even as the killer silently brewed in your gut, you’d push your bags through security, perhaps even pick up a croissant at the coffee shop and enjoy a brief respite in a cool molded-plastic chair at the gate before a crackly PA announced the boarding of your flight.

It would be only after you’d shuffled down the plane’s aisles and found your lightly tattered upholstered seat that the stranger within would make itself known, in a deadly, explosive onslaught of excretion, and your trip overseas would be suddenly and cruelly curtailed. Without the benefit of modern medicine rapidly administer,d you’d be faced with a fifty-fifty chance of survival.

I think the above selection makes it abundantly clear that, if the reader is of a rather nervous disposition, it might not be very wise to pick this book up unless they are absolutely certain of what they are about to get themselves into. I myself felt a touch nauseated in some parts of the book, and I like to think I have a rather strong stomach when it comes to these sorts of things.

But why cholera? If an author of a book about pandemics wants to talk about historical pandemics with relevance to the contemporary world, why not the 1918 influenza – the one that probably killed more people than all the battles of World War I combined? After all, influenza is one of the greatest viral threats to the world, and many of Shah’s readers will likely remember the H1N1 flu pandemic that happened in 2009. Shah explains her decision to use the 19th century cholera pandemic as her historical point of comparison in the following excerpt:

Cholera is one of only a handful of pathogens—including bubonic plague, influenza, smallpox, and HIV—that in modern times have been able to cause pandemics… Among them, it stands alone. Unlike the plague, smallpox, and influenza cholera’s emergence and spread were well documented from the beginning. Two centuries after it first emerged, it remains exceptionally potent, with an undiminished power to cause death and disruption… And unlike relative newcomers like HIV, cholera’s an old hand at pandemics. So far, it’s caused seven, the latest hitting Haiti in 2010.

Today cholera is known primarily as a disease that affects impoverished countries, but that wasn’t always so. In the nineteenth century, cholera struck the most modern, prosperous cities in the world, killing rich and poor alike, from Paris and London to New York and New Orleans. … Over the course of the nineteenth century, cholera sickened hundreds of millions, killing more than half of its victims. It was one of the fastest-moving, most feared pathogens in the world.

But Shah’s narrative of the history of cholera is mostly a frame for a more pressing concern: the current wave of pandemics that are occurring today. Sometimes it seems like not a year passes without some new disease breaking out into the world, with paranoia and hysteria following in its wake, and it can sometimes feel like humanity is helpless against these new biological threats. Shah, however, points out that history can show us the way:

By telling the stories of new pathogens through the lens of a historical pandemic, I could show both how new pathogens emerge and spread, and how a pathogen that had used the same pathways had already caused a pandemic. The path from microbe to pandemic would be illuminated in the overlap, where two dim beams intersected.

Shah succeeds admirably in the above goal. By taking apart the history of cholera, she shows the true complexity underlying a pandemic. It is not so straightforward as a pathogen becoming deadly enough and virulent enough to be a true safety concern, nor is it just about scientists conducting research in the field or in laboratories. Pandemics occur, she claims, through complex interactions of history, economics, politics, and culture. “Epidemics are sparked by social conditions as much as they are by introductions,” she states in Chapter 6, and that is quite true. Even a cursory look at the ongoing Zika outbreak shows how a good grasp of culture and societal conditions is key to not only predicting where Zika will show up next, but ultimately, how it might be contained, or even cured. The same applies to any future pathogens that may emerge in the future.

Underpinning all of this is Shah’s writing. There is a sense of urgency in it that drives the book forward, though it must be noted that that urgency can also sound a little bit like sensationalism in some places; fortunately that does not happen very often. This is just a minor complaint on my part, though, as it does not really interfere overmuch with the rest of the book

Overall, Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond is a book that more people should read, despite the discomfort it is bound to induce. By combining historical accounts, the latest scientific research, and her own personal experience, Shah is able to show a possible path that humanity can take in confronting the biological threats that lie just beyond the horizon. Taking a multidisciplinary approach to the study of disease is merely the first step, but it is, perhaps, the most important one, because it is only by understanding how humanity interacts with the world – both inside and outside our bodies – that we can begin to find a way to understand what makes a pandemic, and hopefully, stop them from happening.

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