Like every other species on the planet, humans suffer from infectious diseases caused by bacteria, viruses, fungi, and other microorganisms. What sets us apart is a set of nifty tricks—the fruits of several centuries of scientific and medical advances—that allow us to strike back and gain a measure of control. And yet, as Norwegian professor of medicine Stig S. Frøland writes, this is a duel without end: we can win many battles, but we will never win the war. This book, driven by his interest in history and backed by his medical expertise, provides a good all-round introduction to the history of infectious diseases and the many ways in which we have sought to prevent and cure them.

Duel Without End: Mankind’s Battle with Microbes, written by Stig S. Frøland, published by Reaktion Books in April 2022 (hardback, 632 pages)

There is no shortage of recent big history books on disease. Most recently I was impressed by Kyle Harper’s tome Plagues Upon the Earth. Duel Without End was originally published in Norwegian in 2020 as Kampen Mellom Mennesket og Mikrobene by Dreyers Forlag. Reaktion Books has enlisted John Irons for the English translation. At the surface of it, this seems like a potted history of celebrity diseases, and the book is written expressly for readers without previous specialized knowledge. However, Frøland brings relevant expertise to the table thanks to his medical background. He structures this book using two frameworks.

The first encompasses the participants—man and microbe—but especially their environmental and ecological interactions, which are partially shaped by human behaviour. These factors include the rise of cities, warfare (always a sure recipe for disease outbreaks), infections from (domesticated) animals, trade and travel, and sex and drug use. It includes the double-edged sword of medical technology that extends lives but also creates populations of vulnerable, immuno-compromised people. It includes anthropogenic changes to landscapes. We are becoming increasingly aware that habitat destruction brings with it the risk of zoonoses: when human and animal populations come into contact, diseases can spill over from the latter into the former. Lastly, it includes the complex interaction between climatic changes and disease.

“At the surface of it, this seems like a potted history of celebrity diseases […] However, Frøland brings relevant expertise to the table thanks to his medical background..”

The second framework is a temporal one. Frøland recognizes five transitions in human history where conditions and opportunities for microbes changed drastically, many of which are related to the above interactions. To wit: agriculture and animal domestication, the Columbian Exchange when European colonisers landed in the Americas, the Industrial Revolution during which sanitary conditions and hygiene standards improved, the discovery of bacteria in the 19th century, and the rapidly increasing globalisation after World War II (something other authors refer to as The Great Acceleration). He is more upbeat than Jared Diamond who called agriculture our biggest mistake. Sure, Frøland writes, health initially took a hit, but it laid the grounds for later improvements that have more than compensated for this. He also singles out the influential ideas of social scientist Thomas McKeown who has argued that improved nutrition was the key factor behind increased lifespan, rather than breakthroughs in our medical and bacteriological understanding. Though several valid objections to this have been raised over time, the idea still pops up in popular discourse, e.g. when people question what medicine and vaccines have ever done for us.

With these two frameworks introduced, and after briefing the reader on the basics of microbiology, immunology, infection biology, and population genetics, Frøland turns to his history of infectious diseases. A stonkingly large chapter 4 that sprawls over 225 pages discusses the famous epidemics and pandemics of the past: bubonic plague (a section I took particular interest in given I have subjected myself to Benedictow’s book The Complete History of the Black Death), smallpox, typhus, cholera, measles, yellow fever, syphilis, tuberculosis, leprosy, malaria, influenza, and polio. An additional historical chapter deals with the mystery epidemics of the past where we still have no good idea of the pathogenic cause. A third chapter deals with the challenge of emerging infectious diseases: Ebola, HIV, SARS, Zika, and many others besides. Given that this book was originally written before the COVID-19 pandemic took off, that section will have been added in translation and is necessarily somewhat cursory and already outdated on some points. What was striking is that Frøland mentions influenza as the most likely next pandemic, even though virologists, writers, and the World Health Organisation have prominently worried about coronaviruses.

These chapters are very informative and nicely combine epidemiological and historical details. Next to macro-historical patterns of how certain diseases spread and where they might have originated, Frøland ties them to the above-mentioned frameworks of ecological interactions and the five microbial transitions. Repeatedly, he shows how pathogens took advantage of humans rearranging the world around them. Furthermore, he mentions (famous) victims; a long list of notable syphilis sufferers is presented, for example. Fortunately, he avoids speculative historical counterfactuals (i.e. “if disease X had not broken out, would event Y still have happened?”) Though interesting, he does not consider them a terribly useful way of studying history.

“A level-headed, measured approach characterises much of the book, complemented by a healthy dose of myth-busting.”

This same level-headed, measured approach characterises the rest of the book, which tackles a plethora of related topics. Frøland takes a good look at the possibility of diseases leading to the fall of empires. While admitting that such collapses were complex and multifactorial—it is never just one thing—he does think that we downplay the importance of infectious diseases. Next to historical curiosities, understanding these processes will hold important lessons for the future. He discusses a long list of countermeasures, everything from human behaviour to vaccines, antibiotics, drugs, and therapies. And there is an equally in-depth discussion of future challenges, everything from antibiotic resistance to the dangers of gain-of-function experiments in biomedical research and the possible effects of climate change.

There is a healthy dose of myth-busting. Were plague-ridden corpses really catapulted into the besieged city of Kaffa in what has been called the first known example of microbial warfare? It is a good story, but fleas rapidly abandon cold corpses, so beyond the shock factor it would not do much to spread bubonic plague. Furthermore, Frøland avoids the Big Man narratives that you often encounter in popular representations of scientific discovery. We celebrate Louis Pasteur and Robert Koch for their microbiological discoveries while forgetting all the others on whose work they built. He questions the mythology around Lady Mary Wortley Montagu and Richard Jenner in the history of vaccines, and the apocryphal story of how Alexander Fleming discovered penicillin. Furthermore, Frøland is measured regarding what we do and do not know about, for instance, the microbial cause of chronic diseases or the actual threat of zombie viruses waking up as the world’s permafrost melts. And he shows a welcome degree of moderateness when discussing the balance between anti-epidemic measures and the costs to societies and individuals. As a medical doctor, he is less strident than you might expect when considering the very serious issue of vaccine hesitancy, and whether coercive measures are a good way of dealing with this.

As usual with publications from Reaktion Books, the book is richly illustrated, in this case with 59 colour and 89 black-and-white photos and illustrations. I admit that I did not find the writing as captivating as Kyle Harper’s, but there is so much interesting historical material here that the book grips you in its own way. Overall then, Duel Without End is a broad, all-round introduction to the history of epidemics and pandemics that favours level-headed discussion over hyperbole.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

Duel Without End

Other recommended books mentioned in this review:

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It might sound crass to write that the COVID-19 pandemic is just the latest in a long line of infectious disease outbreaks, but a little perspective helps. Historian Kyle Harper previously impressed me with his study on the role of climate and disease in the decline of the Roman Empire. In Plagues Upon the Earth, he offers a global, multidisciplinary environmental history of infectious disease, showing that it is a force that has both shaped and been shaped by human history. This magnificent book stood out as much for its nuance and academic rigour as it did for its readability.

Plagues Upon the Earth: Disease and the Course of Human History, written by Kyle Harper, published by Princeton University Press in October 2021 (hardback, 686 pages)

There is currently no shortage of big history books on pandemics. What makes Plagues Upon the Earth stand out? Briefly, it is so much more than just a potted history of “celebrity” diseases such as bubonic plague, smallpox, or measles. In particular, Harper carefully revisits existing narratives in light of new data and methods, although here I can only touch on a fraction of what impressed me. I am not normally in the habit of writing reviews in the form of listicles, but what follows are seven reasons why I think this book is worth your time.

First, it is appropriately evolution-centric, with the first two chapters focusing on microbiology, primatology, and especially evolutionary biology. Harper’s discussion of horizontal gene transfer, the mind-blowing concept of viral quasispecies, or the relentless nature of evolution shows he has read the relevant literature and can explain why viruses and microbes outwit us time and again.

Second, and equally appropriate, the book is germ-centric: “it’s a microbe’s world. We’re just living in it” (p. 20). From their perspective, we are “warm, nutrient-rich, well-defended host environments” (p. 43) that, incidentally, also took over the world. A recurrent theme is that disease ecology shapes us as much as we shape it. Harper warns that “we should not treat the biology of disease like a kind of ghost in the machine, beyond all explanation” (p. 333). Two examples will have to suffice. We have identified 5000-year-old bubonic plague victims, but pandemics only became inevitable later, after “humans built an ecosystem for the rapid, continental-scale transmission of animal germs” (p. 201). That is, only after rats had spread globally in the wake of trade, urbanization, farming, and grain storage. Then there are the human factors contributing to the general crisis of the 17th century. Harper details how population pressure and food shortages, urbanization, unsanitary conditions in new institutions such as jails and hospitals, and more and larger military conflicts all worsened infectious disease outbreaks.

“the book is [appropriately] germ-centric […] A recurrent theme is that disease ecology shapes us as much as we shape it.”

Third, Harper pays particular attention to new studies on evolutionary relatedness (phylogenetics), whole-genome sequences (genomics), and DNA recovered from archaeological remains (ancient DNA). Does this kind of data have a special status? I would argue so: compared to historical records, DNA is eyewitness testimony without an ideological axe to grind. As with The Fate of Rome, Harper is not out to overthrow established narratives but to carefully reexamine them to see what genetics can add. The following is but a sampling of many interesting findings discussed. Agriculture seems to have spread by farmers pushing out hunter–gatherers, rather than the latter adopting farming practices. Morbiliviruses jumped from rodents and bats via cattle to humans. So, rather than cattle making us sick, we created a zoonotic bridge by animal domestication, “making rinderpest just as much an unintended side effect of human social development as measles” (p. 169). Similarly, human tuberculosis is surprisingly young, but bovine tuberculosis is younger still: we made our cows sick. And unlike a decade ago, we now have solid evidence that the bacterium Yersinia pestis did cause the bubonic plague of the Middle Ages. Harper still references the first edition of Ole Benedictow’s The Black Death. It will be interesting to see if the second edition, published this March as The Complete History of the Black Death, has accounted for the flood of new genomic data.

Fourth, Harper brings similar nuance to conventional historical narratives. Agriculture has a bad reputation amongst historians. Palaeopathological findings, such as those gleaned from teeth, do not lie: our health suffered when we started farming. However, this narrative “distorts the role of infectious disease in the deep past” (p. 79). Agricultural villages were too small to sustain chains of transmission of respiratory crowd diseases: “Big city life, and big city death, were things of the future” (p. 162). What sedentary life with domesticated animals and without sewers did bring was mountains of poop. And with it the faecal–oral transmission of a slew of oft-overlooked intestinal diseases. Similarly, the discovery of the New World has been called the Columbian Exchange: we took away new crops and left behind lethal germs, an idea further popularised by Jared Diamond. Though true, focusing on disease makes “the depopulation of the New World seem like a lamentable accident, minimizing the role of violence and deliberate exploitation” (p. 243).

Fifth, this book highlights overlooked diseases (e.g. neglected tropical diseases and abovementioned intestinal afflictions) and historical actors. The period from ~1670 to 1820 was an age of receding pandemics, often credited to the Enlightenment. But, adds Harper, the rise of institutions and nation–states was just as important. “Improvements in life expectancy are generated not by ideas alone but by ideas that are put into action, especially by capable governments” (p. 384).

“As with The Fate of Rome, Harper is not out to overthrow established [historical] narratives but to carefully reexamine them to see what genetics can add.”

Sixth, and related to this, history is rarely a linear march of progress and Harper highlights overlooked periods of setbacks. The age of receding pandemics was followed by new disease outbreaks in the 19th century—such as cholera, yellow fever, and influenza—all of which piggy-backed on the invention of steamships and railroads. Long-distance trade and bulk shipping of tropical foodstuffs created a new global disease ecology for humans, animals, and plants alike. “More often than not, the outbreaks of the nineteenth century came in peace” (p. 429). One of the most fascinating ideas in this book is that of 14th-century Arab historian Ibn Khaldun who recognized that epidemics do not just result from societies failing, but also from them being successful. Harper calls it a profound insight: at least in agrarian empires, demographic upswings also could trigger lethal epidemics and social disintegration.

Finally, Plagues Upon the Earth is rigorous yet readable. Harper draws on a huge body of academic literature, providing 90 pages of references and 59 pages of endnotes with interesting asides and advice on recommended reading. Though as I hope the above quotes show, he has a knack for writing an engaging narrative. Have I missed anything? Yes, I have not even mentioned the last three chapters that detail the long and winding road that ultimately made us understand and then overcome many infectious diseases, involving one chapter that explores the putative link between economic growth and mortality decline.

Harper mentions that he started working on this book years before all hell broke loose. Though he grants it is too early to take stock of the COVID-19 pandemic, he reiterates that we were warned time and again. “For scholars who study the past or present of infectious disease, the pandemic was a perfectly inevitable disaster […] its contours predictable, its details essentially random” (p. 504). Our shared history with germs should be classroom material. Harper expresses this call to arms most powerfully right at the start: “We do not, and cannot, live in a state of permanent victory over our germs. Eternal vigilance is the price of liberation from infectious disease, but interruptions are inevitable, not anomalous” (p. 3).

Plagues Upon the Earth is a phenomenal achievement and my recommendation of the year for background reading on the COVID-19 pandemic. This is a big book that is well worth your time.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

Plagues upon the Earth

Other recommended books mentioned in this review:

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So far, most of the books I have read on the COVID-19 pandemic have either been of the backwards-looking, how-did-we-get-here type, or have dealt with practical virological, epidemiological, or immunological details. I picked up Apollo’s Arrow as it promised a forward-looking perspective while drawing parallels with past pandemics. Nicholas A. Christakis, a physician and sociologist directing the Human Nature Lab in Yale, got drafted into working on the pandemic from the start, tracking the spread of the virus, and sat at the bedside of many dying patients while working as a hospice doctor in New York. I believe we need to hear these frontline stories.

Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live, written by Nicholas A. Christakis, published by Little, Brown & Company in November 2020 (hardback, 384 pages)

Accompanied by excellent infographics by Cavan Huang, Apollo’s Arrow provides you with all the basics in case you need them. Christakis starts with an overview of how the virus was first detected in China and then spread around the world. He details the differences with the SARS and Spanish Flu pandemics to explain why COVID-19 became so destructive, along the way introducing epidemiological parameters and details such as infection fatality rates, case fatality rates, the basic reproduction number R₀, herd immunity, asymptomatic transmission, the concept of flattening the curve, and how exponential growth keeps catching us out. Usefully, he also discusses the full range of non-pharmaceutical interventions that we have at our disposal: physical distancing, mask-wearing (a basic topic some other authors have omitted), testing and tracing, border closures, and lockdown.

Throughout, Christakis includes eyewitness testimony of, and insightful comparisons to, past pandemics. From recent ones such as SARS, influenza pandemics in 1957 and 1968, and the Spanish Flu, to historical ones such as the bubonic plague or the plague of Athens, pandemics have long been with us, shaping the course of history. I think there is much value in providing historical perspective, and there is no shortage of recent books surveying pandemics through the ages, many now being reissued with new chapters or added prefaces. What sets apart Apollo’s Arrow is that it focuses on COVID-19 through the eyes of a physician who is interested in history. As Christakis discusses the short, medium, and long-term consequences of the pandemic, the past is a constant companion to show that “What happened in 2020 was not new to our species. It was just new to us” (p. 84).

“As Christakis discusses the […] consequences of the pandemic, the past is a constant companion to show that “What happened in 2020 was not new to our species. It was just new to us“”

There are the familiar companions of grief, over lives and livelihoods lost; fear, and the scapegoats on who we take it out; and lies, the conspiracy theories and propaganda. What has not helped the disease being taken seriously, Christakis writes, is that COVID-19 lacks visible symptoms. And with many people dying alone in healthcare facilities, “Americans did not see how the virus did its awful work” (p. 204). As has historically happened, much of the impact ran along the faultlines of existing inequalities, with groups such as Hispanic and African American communities, homeless people, prisoners, or meatpackers particularly hard-hit. But the coverage here is not all negative. Unsurprisingly from an author who wrote Blueprint, he highlights the healthcare workers who put their lives on the line, and the altruism and charity as everyday people helped each other in myriad ways. The penultimate chapter is a grab bag of observations and questions—some speculative, others less so—on how the pandemic affected for instance the environment, children and education, the economy and supply chains, jobs, religious beliefs, or practices in public health care.

I was particularly pleased to see Christakis repeatedly mention the Three Horsemen of the Apocalypse: “The lack of scientific literacy, capacity for nuance, and honest leadership” (p. 320). Unique to our time, social media provided “a bonanza of disinformation” (p. 151), while academic preprint servers containing unvetted information proved to be a double-edged sword. It has been galling to see basic, uncontroversial hygiene practices being drawn into politicized discussions over “personal freedom”, ignoring its partner-in-crime, “collective responsibility”. Or to see delusional wishful thinking, as if the pandemic “could end by fiat” (p. 319). Christakis reminds us that “[…] denial is an old ally of pathogens” (p. 157).

“[Unless] you have religiously kept up with the deluge of news items and opinion pieces on the pandemic […] this book is a welcome and well-written perspective from a qualified professional, looking forward from his particular point in time.”

For those inclined to unwarranted accusations at the address of “elitist academics”, the above is coming from a physician critical of his own profession. He thinks the privacy lost to contact tracing apps is not worth the limited epidemiological benefits and high likelihood of false positives. He remarks on the surprisingly small role of medicine in the historic decline of most infectious diseases, which are instead largely due to socioeconomic improvements and basic public health measures. And he points to iatrogenesis: illness or injury caused by medical actions, something that actually declined during the pandemic as many operations and hospital visits were delayed.

So far, so good. Christakis offers plenty of sharp observations to digest. I have, however, two caveats. First, as the publisher’s blurb also points out, this book is rather US-centric. Second, the book is dated in places. This is not a criticism of the author; rather, the pandemic is a rapidly moving target and I am to blame for reading this book as late as I have. Especially his concern that we might not have vaccines in good time seems cautious with the benefit of hindsight. Their rapid development has been a noteworthy achievement, and other authors are already lining up to tell these success stories. I hasten to add that it has been a typical human achievement, replete with follies such as vaccine nationalism as countries competed to secure supplies.

Even though some of Christakis’s questions and concerns have been supplanted by new ones, many others remain. If you have religiously kept up with the deluge of news items and opinion pieces on the pandemic, a lot has already been discussed since. But I imagine that for many readers, myself included, life will have gotten in the way. If so, then this book is a welcome and well-written perspective from a qualified professional, looking forward from his particular point in time. It does present the author and the publisher with a challenge for the paperback that is slated for October 2021. Reissuing the book as-is does not strike me as very useful. But bringing it up to date with the many developments since then would be a mighty task, tantamount to rewriting it. If Christakis were to go down the route of a thorough update, I have no hesitation in recommending that you buy the paperback upon release. I can see how the hardback will have been very impactful upon publication last year, and I found the comparisons with past pandemics to be particularly eye-opening.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

Apollo’s Arrow

Other recommended books mentioned in this review:

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A pandemic is probably a good moment to understand how vaccines are developed and how they work. This short and educational primer offers relevant background information on viruses and the immune system, and goes into much more detail on vaccines than other recent introductory books. How to Make a Vaccine is written by immunologist John Rhodes who brings to the table both his background in academic research on vaccines and his experience working for GlaxoSmithKline from 2001 to 2007. His narrative approach of choice is to tell the story of viruses, immunology, and vaccines through the history of scientific discovery.

How to Make a Vaccine: An Essential Guide for COVID-19 & Beyond, written by John Rhodes, published by the University of Chicago Press in March 2021 (paperback, 184 pages)

Some of these historical episodes were by now familiar to me. For example, Charles Maitland’s first variolation experiments on prisoners, Edward Jenner’s use of cowpox vaccine to combat smallpox, and the 1950s race for a polio vaccine between Jonas Salk and Albert Sabin. Or the bizarre history of the 19th-century maritime expeditions to distribute the first vaccines around the world, keeping them alive on the long journeys through a carefully orchestrated living chain of infection. Other episodes were new to me. For example that Jenner was not the first to experiment with cowpox vaccination. How Wendell Stanley first visualized viruses under an electron microscope in 1935, and how June Almeida first visualized coronaviruses in 1968.

The only place where I felt this historical approach broke down a bit was when it came to the immune system, which is a complicated topic. The components of our byzantine immune system were not necessarily discovered in a logical order, and I would have loved some illustrations here. Instead, there is a useful table on page 22 summarising the different B and T-cells and their myriad tasks. Nevertheless, I found Rhodes’s explanations of how the different components of the immune system function the clearest I have come across so far. For example, I keep confusing antibodies and antigens (I know, as a biologist I should be ashamed for having to admit this). However, when Rhodes writes “the fragments of germs (pathogens) […] soon became known as antigens” (p. 16) it finally activated a mnemonic in my head.

“[…] I found Rhodes’s explanations of how the different components of the immune system function the clearest I have come across so far.”

Chapters four and five are, to me, the core of this book and obligatory reading. I found them exceedingly useful. The first explains the six steps in vaccine development: exploratory, preclinical, phase I, II, and III trials, and regulatory review. This strict procedure ensures vaccines are safe. In part, it is a product of past errors, such as the 1955 Cutter Incident when a particular batch of polio vaccines had not been properly prepared. The only question I felt Rhodes could have asked and answered more explicitly is how COVID-19 vaccines could be developed so quickly. Many people worry that they have been rushed and might not be safe. You have to read between the lines a bit, but the answers are there. For instance, existing vaccine platforms that can quickly be repurposed, technological advances in genetic sequencing and engineering, rapid dissemination of new findings through open publishing platforms and preprint servers, and financial investment such as Operation Warp Speed in the US. Importantly, a large fraction of your population is exposed to the disease during a pandemic, which allows you to rapidly see what fraction of vaccinated people still fall ill, i.e. how effective your vaccine is. Normally, gathering enough data to draw statistically robust conclusions takes a long time, and an epidemic might burn itself out before you get a chance to do so. As a result of all this, there were 232 (!) candidate vaccines when this book went to print.

The second chapter walks you through the six established types of vaccines. All vaccines rely on exposing your immune system to an antigen to activate an immune response, but there are different approaches. Rhodes provides much more detail and for each type also gives examples of COVID-19 vaccines that are being developed. But, briefly, one way of categorising them is the non-living versus living vaccines. The former use dead viruses, parts of viruses (protein subunits), or virus-like particles, but typically need an additive, a so-called adjuvant, to elicit a sufficiently strong immune response. The latter are more potent and rely on living but weakened viruses or use a replicating or non-replicating carrier, a so-called vector, that is modified to contain fragments of a particular virus.

“Chapters four and five are, to me, the core of this book and obligatory reading. I found them exceedingly useful. The first explains the six steps in vaccine development […] The second chapter walks you through the six established types of vaccines.”

And then there are the new kids on the block, DNA and RNA vaccines, which differ in that they get straight to the heart of the matter. After all, the sole purpose of a virus is to deliver its DNA or RNA to a host cell and commandeer its machinery to produce more viruses. These vaccines achieve the same by directly administering engineered pieces of DNA or RNA that code for viral proteins. As Rhodes highlights, especially RNA vaccines hold great promise as they do not replicate, do not integrate into the host’s DNA, interact directly with the cell’s machinery without intermediate steps, and, like other RNA fragments, after a while are naturally broken down by resident housekeeping enzymes. Both the Pfizer and Moderna vaccines that are currently being rolled out to combat COVID-19 are RNA vaccines.

Finding and testing vaccines are only the first steps to getting a virus under control, so I was very pleased to get an immunologist’s perspective on the additional hurdles. This concerns practical logistical problems such as mass-producing billions of syringes and glass vials, figuring out who should be vaccinated first, and the problem of nations competing rather than collaborating to get their hands on vaccines.

“[…] I was very pleased to get an immunologist’s perspective on the additional hurdles. This concerns practical logistical problems [but] more importantly […]the vexing problem of what he understatedly calls vaccine hesitancy.”

More importantly, however, Rhodes addresses the vexing problem of what he understatedly calls vaccine hesitancy. I found his approach here admirably balanced. He gives the background to a few infamous vaccine scare stories (e.g. the Wakefield affair) while explaining some of the actual problems that can sometimes arise, and how lessons have been learned from this to design safer vaccines. Nor does he trivialize the anti-vaccination movement entirely: “Is it right to attribute all issues of vaccine refusal to superstitions, conspiracy theories, and irrationality? Of course not.” (p. 114), while highlighting more subtle reasons. At the same time, he makes the sharp observation that we need to rebalance “perceptions of individual liberty versus collective responsibility and the good of the community” (p. 116). This, I would add, is true of several other public health measures over which some vocal minority groups have been making a right kerfuffle.

How to Make a Vaccine joins several recent pocket-sized paperbacks that offer brief overviews, whether it is of viruses in general, SARS-CoV-2 in particular, or the botched response of governments. It is an especially nice complement to Chakraborty’s and Shaw’s Viruses, Pandemics, and Immunity that focused more on the immune system and only briefly covered vaccines. Helpfully, the further reading section at the back breaks down references per chapter into general and technical literature.

At a time when online searches for books on vaccines are more likely to turn up misinformation than reliable literature, How to Make a Vaccine is a required primer that demystifies concepts and gives an informative overview of how vaccines are developed and how they work. An essential guide indeed.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

How to Make a Vaccine

Other recommended books mentioned in this review:

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Last year August, science writer Ed Yong put it very nicely: “you see, the immune system is very complicated“. Yet, understanding it is important to understanding how the COVID-19 pandemic might evolve, why we are faced with certain public health measures, and how we can hope to combat the pandemic with tests and vaccines. In this brief book, physics and chemistry professor Arup K. Chakraborty and immunologist Andrey S. Shaw offer a general introduction to how our immune system reacts to viruses, and how our medical inventions help out.

Viruses, Pandemics, and Immunity, written by Arup P. Chakraborty and Andrey S. Shaw, published by MIT Press in February 2021 (paperback, 206 pages)

I was particularly looking forward to this book. Amidst the growing crop of books on COVID-19, the immunological details have been somewhat neglected. Kucharski’s The Rules of Contagion looked at the epidemiology of disease outbreaks but was written just before the pandemic materialised (the paperback addresses this to some extent), while Rabadan’s Understanding Coronavirus does what it says on the tin, focusing on the virus, SARS-CoV-2, and the disease, COVID-19.

Viruses, Pandemics, and Immunity is nicely balanced in the way it treats all the relevant elements to understand this topic. You get two chapters with history, introducing you to early procedures and to important scientists such as Edward Jenner, Robert Koch, and Louis Pasteur. By the end of it, you will understand the difference between variolation and the vaccine methods of respectively Jenner and Pasteur. This is followed by three chapters with the scientific nuts and bolts, looking at viruses, the immune system, and epidemiology, and two final chapters looking at the medical countermeasures of antiviral therapies and vaccines. In all of these chapters, details and findings on SARS-CoV-2 and COVID-19 are highlighted.

“Viruses, Pandemics, and Immunity is nicely balanced in the way it treats all the relevant elements to understand this topic, [highlighting] details and findings on SARS-CoV-2 and COVID-19.”

I admit that I found the middle three chapters a bit hit and miss. The one on viruses is, I think, great, explaining how viruses work by taking over the host cell’s replication machinery, how DNA and RNA viruses differ, why COVID-19 went global while SARS and MERS—also caused by coronaviruses—did not, and how SARS-CoV-2 differs from other RNA viruses that we understand better, such as influenza and HIV.

In light of what I said earlier about the immune system, it is not surprising that the chapter on immunity is the longest. It introduces the two components of our immune system, innate and adaptive, and how both function when the body detects an intruder. The innate immune system is, relatively speaking, the simpler of the two, responding to infection immediately by recognizing general characteristics of bacteria, viruses, and fungi. The authors can describe this in five pages, including details on Toll-like receptors and cytokines. The adaptive immune system needs more time to gear up, 5–10 days in humans, and is the more complex of the two. In some 20 pages, the authors here introduce the byzantine arrangement of B lymphocytes that combat viruses directly, and T lymphocytes that destroy infected cells in the body, as well as the memory cells that both types contribute. But rather than discuss the innate and adaptive immune system in the order in which they get activated, the authors discuss them in reverse order, which I found a bit counterintuitive. Given the complicated nature of the beast, the level of detail might challenge readers not well-versed in biology, though a helpful “putting it all together” section runs you through it all again at the end of the chapter.

“Given the complicated nature of the [immune system], the level of detail might challenge readers not well-versed in biology, though a helpful “putting it all together” section runs you through it all again […]”

Similarly, the chapter on epidemiology explains the relevant concepts: the basic reproductive number R₀, epidemiological models, the effects of public health measures (“flattening the curve”), and herd immunity. The authors also highlight why different countries have been less or more successful in addressing the pandemic, something that will be explored in-depth in Fighting the First Wave. But here, too, the writing sometimes gets a bit complex. The authors spend three pages on a convoluted explanation with numerical examples to tell you that the more infectious a virus is, the higher the fraction of your population that needs to be immune before herd immunity kicks in. Furthermore, they exclusively discuss social distancing and different strategies to achieve herd immunity, from intermittent lockdowns to simply “weathering the storm”. But the two other pillars of public health measures, hand washing and face masks, are not even mentioned, even though they make important contributions to reducing R₀.

The last two chapters are spot on again, focusing on the two main weapons in our medical arsenal. Antiviral therapies block one or more steps (entry, replication, assembly, and release) in the viral lifecycle and there is a brief discussion of existing antiviral therapies such as remdesivir and dexamethasone that have been repurposed for use against SARS-CoV-2. Vaccines, then, stimulate our immune system and this is where the immunological details come in again. How to Make a Vaccine covers all these topics in more detail, but there is a good introduction here to the different types of vaccines, clinical trials, and vaccine development, as well as the logistical challenges of the currently required large-scale production and a brief note on why vaccines are safe and certainly preferable over the alternative. Unavoidably, when discussing promising vaccine candidates against COVID-19, some information is already dated. The Moderna vaccine was undergoing trials when this book was written, while the AstraZeneca and Pfizer ones were in the developmental stages. All three are now being rolled out.

“[…] the book is livened up with cartoony illustrations [though] the decision to not include figure captions limits their utility.”

Throughout, the book is livened up with cartoony illustrations by Philip J. Stork, a senior scientist at Oregon Health & Science University. However, the decision to not include figure captions limits their utility in my opinion. Despite annotations in the figures, some are quite cryptic by themselves. Captions could have formed the perfect bridge and condensed the sometimes complex details found in the body of the text.

Viruses, Pandemics, and Immunity bundles introductions to a number of relevant topics, effectively replacing the need to e.g. get several Very Short Introductions. By highlighting what we know about COVID-19 and SARS-CoV-2 for each of these topics, this welcome book plugs a gap, especially where the immune system is concerned. General readers will want to heed Yong’s warning though, because, you see, the immune system is very complicated.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

Viruses, Pandemics, and Immunity

Other recommended books mentioned in this review:

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Out of the first crop of books relating to the coronavirus pandemic, this one seemed especially relevant. Author Richard Horton is the editor of the leading medical journal The Lancet which has been an important publication outlet for new research results on both the virus SARS-CoV-2 and the disease COVID-19. Having also served at the World Health Organization (WHO), Horton thus has had an insider’s view of the pandemic and here brings a sharp critique to bear on the sluggish political response in Europe and the US.

The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again, written by Richard Horton, published by Polity Press in June 2020 (paperback, 133 pages)

As I have done previously, let me just briefly comment on what is not in the book. The COVID-19 Catastrophe really focuses on the science-policy failures that have allowed this disease to rampage out of control. At only 133 pages, this does not leave much room for anything else, so for a primer of the biological details known so far, I once again refer readers to Understanding Coronavirus.

Something that other books have only touched upon, but that Horton reveals more about here, is what happened in China in early January: how early warnings from doctors were gagged before the news reached Beijing, and how the WHO got involved. This culminated in the WHO issuing a PHEIC, a Public Health Emergency of International Concern, which is the most serious warning they can send into the world.

“Horton […] focuses primarily on the lessons not learned from the 2002–3 outbreak of the SARS virus. A painful highlight is the 2016 […] tabletop exercise Cygnus which simulated a scenario of pandemic influenza, showing that the UK was not prepared.”

Other books such as Spillover and COVID-19 have pointed out that virologists have been warning of the threat of pandemics for decades, and both books give detailed histories of previous pandemics such as HIV, Ebola, SARS, MERS, and others. Horton mentions these briefly but focuses primarily on the lessons not learned from the 2002–3 outbreak of the SARS virus. A painful highlight is the 2016 UK government tabletop exercise Cygnus which simulated a scenario of pandemic influenza, showing that the UK was not prepared. Even so, nothing much has been done with all this information. Horton blames it on a combination of factors. Complacency in the face of warnings. A widespread arrogant attitude that Western societies are somehow above nature, untouchable by disease. And the political unwillingness to place public health ahead of economic growth, which shows in the lack of stockpiling of medical supplies and protective equipment, the lack of investment in research and disease surveillance, and, worse still, continuous budget cuts in the health sectors of most developed nations.

When the inevitable finally did happen, subsequent actions, or lack thereof, only made things worse. This is where Horton is at his most strident, pointing out the weeks and months that passed in which governments did not prepare themselves, thinking they could somehow escape unscathed as if viruses respect borders; the too-little-too-late attempts to contain the virus through lockdowns; the political blame games rather than international collaboration; the confused, contradictory, and sometimes misleading messages from politicians towards the public (the UK and the US are mentioned in particular); the lack of protective equipment for medical personnel etc. If you have followed the news, this has become a sad but recognisable litany of failures by now.

“[…] months […] passed in which governments did not prepare themselves, thinking they could somehow escape unscathed as if viruses respect borders.”

The publisher described this book as hard-hitting, one reviewer mentioned it pulls no punches, The Guardian called it “a polemic of the first order”, and Revolutionary Socialism in the 21st Century “uncompromisingly scathing”. Horton labels Trump’s decision to cut funding to the WHO as a crime against humanity. The UK government’s claims that protective equipment was being delivered to the front lines and that healthcare workers were safe are called bare-faced lies. The failure of governments to protect their citizenry, gross incompetence. Perhaps by British standards Horton is outspoken, but the blunt Dutchman in me sees factual statements here, not hyperbole. I am not sure how you can come to any other conclusion.

Where the roles of China and the WHO are concerned, Horton is balanced. There were questionable things happening in China, and the Chinese government was downplaying the situation or actively suppressing information at various levels within its hierarchy. “There is a gap in the timeline of the pandemic […]” (p. 19) and we need “[…] a more detailed explanation of what took place in Wuhan” (p. 22), writes Horton. But at the same time, Chinese scientists, policymakers, and health workers have been extraordinarily committed and effective in acting and collaborating to contain and defeat this disease. The WHO is similarly described here as an imperfect bureaucratic institution, but one that nevertheless did what it could within its limitations (MacKenzie provided useful background information on these limitations in COVID-19, which Horton omits here). But do not be fooled by governments who are seeking to deflect attention, writes Horton: “to blame China and the WHO for this global pandemic is to rewrite the history of COVID-19 and to marginalise the failings of Western nations” (p. 88). If you take just one thing away from this book, this might well be it.

“”to blame China and the WHO for this global pandemic is to rewrite the history of COVID-19 and to marginalise the failings of Western nations“. If you take just one thing away from this book, this might well be it.”

In the final few chapters, Horton looks towards the future and becomes rather philosophical. He asks what the effects of COVID-19 are on human society so far and turns to the ethics of anthropologist Didier Fassin, highlighting an ethical trend of “biolegitimacy”, of seeing human life in purely biological terms, without considering the political conditions within which it exists. And he draws on the writings of Michel Foucault and Jeremy Bentham’s idea of the panopticon* when pondering what the need for enhanced disease surveillance will mean for our personal freedom. These sections feel somewhat sketchy. I am sure much more could be said about this, but Horton does not develop these themes further here. His list of what our post-COVID world should look like, coupled with his concerns about what will likely happen instead, are pages to take to heart though.

This short and punchy book contains some incisive reporting on how countries failed to act in the face of this pandemic. No doubt, future reporters can explore this topic in far greater depth for many more countries. But we must start this now. Horton has seen first-hand how political disinformation campaigns are already trying to rewrite the narrative of the pandemic. We must document these attempts, he writes, which makes The COVID-19 Catastrophe an urgent and timely book.

In closing, you might wonder how this book compares COVID-19 by journalist Debora MacKenzie, the subtitle of which is very similar to this book. A longer book, it provides more background information on previous pandemics, as well as the role of bats and the complexity of societies in the current one.

* The panopticon is an architectural design for prisons that allows complete surveillance by one security guard without prisoners knowing whether they are being watched.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

The COVID-19 Catastrophe

Other recommended books mentioned in this review:

Saying that the COVID-19 pandemic should not have happened will likely elicit one of two responses. Blaming China for initially trying to cover it up, or saying: “shit happens, this is speaking with the benefit of hindsight”. Appealing as these may sound, they are missing the bigger picture. The awful truth is that we have had this one coming for a long time.

COVID-19: The Pandemic that Never Should Have Happened, and How to Stop the Next One, written by Debora MacKenzie, published in Europe by The Bridge Street Press (a Little, Brown Book Group imprint) in July 2020 (hardback, 279 pages)

Seeing this is a very hot topic, I think it is worth pointing out what you will not find in this book before diving into the rest of the review. Despite the title, you will not find all that much about the virological, epidemiological, or clinical details of COVID-19 and the virus SARS-CoV-2. As we are still in the middle of learning the biological details, you are better off just keeping a close watch on the news. That post-mortem will have to wait—although the primer Understanding Coronavirus provides useful basics on what we know so far.

The clue is in the subtitle. Debora MacKenzie writes this book from her unique vantage point as a veteran journalist reporting on infectious diseases for New Scientist and other outlets for over 30 years. With the world’s attention on pandemics, now is the best moment to draw our collective attention to her shocking tale of neglect and complacency in the face of warnings from the scientific community. This was true when Quammen wrote Spillover, and it still holds today.

“The clue is in the [book’s] subtitle […] now is the best moment to draw our collective attention to [a] shocking tale of neglect and complacency in the face of warnings from the scientific community.”

Judging by what MacKenzie describes here, it has been a perfect storm of various factors that got us to this point. There was a surge of optimism in the 1970s: we eradicated smallpox, we had vaccines to prevent childhood diseases, and antibiotics stopped all sorts of harmful bacteria. A leading medical textbook at the time even declared the future of infectious diseases to likely be very dull. Research departments were downsized as funding dried up. Public health stopped being a state-funded public good as the medical industry was swept up in the wave of privatisation of the 1980s. And networks for research and disease monitoring in developing countries were cast off as excess baggage from colonial times. In short, high on its medical triumphs, the world grew complacent.

But our victory was short-lived.

Ever since AIDS went global in the 1980s, disease experts have been trying to predict what might be the next big threat. We all know of the rise of antibiotic-resistant bacteria, but we also have had plenty of viral near-misses, such as Ebola, Zika, SARS, and MERS. Seeing the relevance of the latter two—they are both caused by coronaviruses—MacKenzie covers their outbreaks in detail. And then there is a whole chapter on flu, the annual recurrence of which has become so routine that we have stopped calling it a pandemic. Next to straightening out the misconception that COVID-19 “is just another kind of flu”, this is relevant because what little governments have in the way of pandemic preparedness plans is based around flu outbreaks. And those prominently do not recommend containment measures: pointless for the fast-moving flu, but relevant for COVID-19.

“[…] MacKenzie asks: what about traditional Chinese medicine? Both horseshoe bats, which carry coronaviruses, and their faeces are ground up wholesale and used to, for example, treat eye infections.”

This is the background against which warnings have been issued and, by and large, ignored. The World Health Organisation (WHO) has had a list of the viral Most Unwanted for years, prominently mentioning coronaviruses. Disease experts, reporters (MacKenzie amongst them), and writers of popular books have sounded the alarm for years. But hey, we have had enough of experts, right? If that was not enough of a slap in the face of science deniers, she ruthlessly despatches some harmful conspiracy theories (no, this virus was not brewed up in a laboratory).

Before getting to proposed solutions, MacKenzie dives down a few rather relevant rabbit holes. One is a very interesting chapter on bats. Bats host numerous viruses that can jump to humans, so they warrant close monitoring. MacKenzie issues a plea to not shoot the chiropteran messenger: certain groups are important pollinators. Plus, and this will not go down well with some but is something I appreciated, human overpopulation and the accompanying encroachment into wild habitats are the root causes here. She dispels as a red herring the idea of pangolins as an intermediate host. But most interesting of all, she casts a shadow of doubt on the whole bushmeat and wet market story. Yes, bats are eaten in parts of the world, but they are usually larger fruit bats. Instead, MacKenzie asks, what about traditional Chinese medicine? Both horseshoe bats, which carry coronaviruses, and their faeces are ground up wholesale and used to, for example, treat eye infections. Next to that potential infection pathway, it involves catching and handling bats. So far this is speculation, but these are reasonable questions to ask. One of the things I really appreciated in this book is that MacKenzie does not mince her words and is not afraid to broach contentious topics.

The other seeming rabbit hole is that of the complexity of our societies. What if a more lethal pandemic emerges? This is a short trip into the science of complex systems, feedback loops, tipping points, resilience to shocks, global supply chains, and, ultimately, the possibility of rapid collapse. Oh, and, depending on your point of view, a  (un)surprising list of typically undervalued and poorly paid jobs that actually keep society running.

“the most important lesson […] is recognizing that profit-driven market forces cannot deliver new vaccines and antibiotics. “

These two topics return in the extended list of seven lessons for the future with which MacKenzie sees the book out. Most of these involve changes at the international level. What we do not need now is blame games. What we do need is more openness and cooperation regarding disease surveillance. Despite some criticism of the WHO here, she also highlights just how limited their budget is, and how their hands are tied due to the sovereign rights of nation-states that can simply hide information and refuse health inspections. We need more preparation, both in the form of research and stockpiling of supplies. We need to recognize systems complexity and accept reduced efficiency (and thus increased costs) to allow more redundancy and resilience in global supply chains. But the most important lesson, I thought, is recognizing that profit-driven market forces cannot deliver new vaccines and antibiotics. This is not about “evil corporations”, it is simply that the risk of failure and the frequent lack of return on investment work against us. This is why we have governments that fund public goods.

MacKenzie admits that COVID-19, written as it was in a mere two frenetic months, is somewhat rough around the edges. Personally, I think illustrations would have helped to explain certain biological details that she presumes understood, and an index would have been useful. But given the circumstances, their omission is perfectly understandable. What the book does deliver is a perfectly-timed, intriguing, and revelatory story of the dangers of ignoring science. And for a debut book, this is all the more impressive.

In closing, you might wonder how this book compares to The COVID-19 Catastrophe by the editor of The Lancet Richard Horton, the subtitle of which is very similar to this book. That book is shorter, focuses exclusively on the science policy failures, and leaves out a lot of the background provided here and elsewhere. It does, however, provide an insider’s perspective of someone who worked for the WHO.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

COVID-19

Other recommended books mentioned in this review:

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With the COVID-19 pandemic shaping up to be one of the most influential public health crises in living memory, it was only a matter of time before books would be written about it. One of the first to make it to press is Understanding Coronavirus by systems biologist and bioinformatician Raul Rabadan. Amidst the swirl of dubious and outright false information that is circulating, there is desperate need for a book that clears up misconceptions and gives a concise introduction to what we know about the virus so far. Given that he spearheaded research in 2009 that confirmed the animal origin of swine flu, Rabadan seems like the right man for the job. Is this the primer that everybody should have on their bedside table?

Understanding Coronavirus, written by Raul Rabadan, published by Cambridge University Press in June 2020 (paperback, 120 pages)

Understanding Coronavirus inaugurates a new series from Cambridge University Press called Understanding Life that offers concise introductions to current biological topics. If you are familiar with Oxford University Press’s Very Short Introduction series, this first book looks a bit like that: a slim, 120-page paperback that will slip in your average coat pocket.

The book consists of an introduction followed by seven chapters written in a question-and-answer format with the table of contents helpfully listing each question. Rabadan mentions it is written for the lay reader with minimal knowledge of biology, virology, epidemiology, or medicine. I would change that to “some knowledge” as it does get rather technical in places. Personally, I got along fine with it but I am somewhat hesitant to give this to, say, my mother.

What Understanding Coronavirus does very well is clarify virology and epidemiology basics. Asking how quickly the virus spreads means explaining the basic reproduction number R₀ and concepts such as “flattening the curve” and herd immunity that everyone has been confronted with. It explains the symptoms, the typical course of the disease, how deadly it is, and that, yes, children and young adults get infected too, but their symptoms are usually less severe.

“What Understanding Coronavirus does very well is clarify virology and epidemiology basics [such as] the basic reproduction number R₀ and concepts such as “flattening the curve” and herd immunity”

Next to these basics it also goes into the frequent comparisons made with SARS and influenza, something specific to this pandemic. Rabadan explains their origins and clarifies the differences and similarities with COVID-19. Regarding SARS, the viruses SARS-CoV and SARS-CoV-2 are very similar, but the diseases are different enough that the World Health Organization gave them two different names. Regarding influenza, Rabadan calls the comparison to COVID-19: “one of the most unfortunate and confusing metaphors from the beginning of the COVID-19 outbreak”. Although we can draw some useful lessons from previous influenza pandemics where public health measures are concerned, the two are not related by any stretch of the imagination. Also, can you explain the difference between seasonal and pandemic influenza? You will after reading this book.

All of this is supported by numerous colour illustrations that demystify concepts. Rabadan’s explanations are concise and the reference list at the back helpfully includes a short note on what each paper or book contains. But I feel that in the middle the book goes off-script somewhat and betrays Rabadan’s specific interests.

“[….] as a bioinformatician and computational biologist Rabadan is fascinated by the evolution of complex systems. […] Now, it is not that these topics are not relevant—because they are—but more to the research community than the average lay reader.”

See, as a bioinformatician and computational biologist Rabadan is fascinated by the evolution of complex systems. Thus he provides details on the molecular biology of SARS-CoV-2: its structure, the size and architecture of its genome, and the cell receptor (a protein called ACE2) that the virus uses to enter host cells. And he specifically discusses how the virus is changing: how we can draw up evolutionary family trees (phylogenetic trees) to track its spread and determine from what animal it jumped to humans (its zoonotic origin). For an evolutionary biologist such as myself, these are mightily interesting details: I did not know that, next to point mutations, viruses also evolve by recombination, just as many other organisms do. But I feel Rabadan almost forgets who he is writing for. For example, when discussing ACE2, he casually mentions that protein levels differ between men and women because (in brackets) “the gene is located on the X-chromosome”. To a biologist, this little throwaway clause makes sense (those are the sex chromosomes, women are XX, men XY, so women have two copies of the gene producing ACE2, etc.), but to most people, this will not be self-evident, I think.

Now, it is not that these topics are not relevant—because they are—but more to the research community than to the average lay reader. What they probably will want to know, and what I found noticeably missing, are questions regarding prevention. Why is washing of hands so important? Why is there a difference between using soap and bottled hand sanitiser? How and why do contact tracing strategies work? Why has there been such conflicting advice on wearing face masks? And how do they work? (hint: it is not just to protect you from others, but especially others from you.) What do we know about the survival of the virus on other surfaces? Can we transmit the virus via clothing or packaging material? Rabadan does mention viral half-life in water droplets and on metallic surfaces in one sentence, but I have been wondering about this. Since viruses are not really alive, they cannot really die. But apparently, virus particles can degrade or decay. How? Is that because of exposure to light or heat? Chemical instability with time? These are the kinds of mundane questions many people have.

“Unsurprisingly, the publishing floodgates have been opened […] amidst this deluge of books, you need to have your basics covered. […] Understanding Coronavirus provides a lot of relevant information in a very readable and concise format.”

One risk of a book published under the current circumstances is that it ages quickly. There is a brief “updates at press” section where Rabadan can just in time point out that hydroxychloroquine, initially considered a promising drug treatment, is not so effective after all, and mention that COVID-19 also seems to attack other organs. Of course, none of this is Rabadan’s fault: the science moves particularly fast in this area and you go with the best information you have at publication.

Unsurprisingly, the publishing floodgates have been opened. Already several books are in the making or due any moment, for instance the reportage COVID-19 from journalist Debora MacKenzie or the very critical The COVID-19 Catastrophe by the editor of The Lancet Richard Horton. Simultaneously, many publishers have spotted an opportunity to reissue older books on pandemics with some extra material: Sonia Shah’s 2016 Pandemic is reissued with a new preface, Mark Honigsbaum’s 2019 The Pandemic Century contains a new chapter, and David Waltner-Toews 2007 The Chickens Fight Back is updated and now titled On Pandemics. I am surprised that David Quammen’s Spillover has not been reissued yet (he has since revisited some of his interviewees for a piece in The New Yorker). And given that Ed Yong has been rehired by The Atlantic to cover the pandemic it does not seem like a crazy idea that he might write a book in due course as well.

Amidst this deluge of books, you need to have your basics covered. Despite a few topics being of interest primarily to scientists while a few other topics are not covered, Understanding Coronavirus overall provides a lot of relevant information in a very readable and concise format. And at this price, you cannot really go wrong.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

Understanding Coronavirus

Other recommended books mentioned in this review:

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With the world in the throes of the COVID-19 pandemic, the questions posed by the subtitle of this book are on everyone’s mind. Associate Professor at the London School of Hygiene & Tropical Medicine Adam Kucharski here takes the reader through the inner workings of contagion. From violence and idea to financial crises and, of course, disease – some universal rules cut right across disciplines. So, is this the most topical book of the year? Well, yes and no.

The Rules of Contagion: Why Things Spread – and Why They Stop, written by Adam Kucharski, published in Europe by Profile Books in March 2020 (hardback, 341 pages)

Kucharski is uniquely positioned to write a wide-ranging book like this. Next to his current position, he is trained in mathematics and did a spot of interning with a bank when the 2008 financial collapse hit. As such, he is at ease explaining both epidemiology and investment banking.

On the disease front, Kucharski covers recent outbreaks of fairly novel diseases such as Zika (which he encountered first-hand in Fiji in 2015), AIDS, Ebola, and SARS. He does not provide the full history of these the way David Quammen did in Spillover, but nevertheless gives you the relevant points in a concise form. Similarly, there is attention for some historical cases such as the miasma theory (the idea that bad air was behind diseases) and how John Snow’s work on cholera in 1850s London disproved this.

Particularly relevant to this moment in time are the epidemiological details, the titular rules of contagion. Kucharski introduces you to the SIR model, which describes how people move through three groups during a disease outbreak (Susceptible, Infectious, Recovered), how this plays into the concept of herd immunity, and how vaccination influences this. He explains the reproduction number R, its four components, abbreviated DOTS (R = Duration × Opportunities × Transmission Probability × Susceptibility), and how this explains why measures such as washing your hands and social distancing have an effect. And then there are those mysterious superspreaders which requires Kucharski to delve into network topology (the architecture of connections in a network). Having read this book, you should come away with a far better understanding of these parameters and mechanisms.

“here is the kicker of the book: these rules [of contagion] are not unique to disease outbreaks.”

But here is the kicker of the book: these rules are not unique to disease outbreaks. Ideas from public health can and have been applied to numerous other fields. This sees Kucharski branch out widely and cover a huge number of seemingly unrelated topics. His internship with a bank has given him an insider’s view of financial contagion, allowing him to clarify pyramid schemes and financial bubbles, but also how the notion of superspreaders applied to the 2008 banking crisis.

The transmission of ideas similarly follows many patterns seen in disease outbreak, although Kucharski is careful to consider ideas other than social contagion for how information spreads. His reminder of some of the psychological biases that can hinder or encourage the spread of information is a topic that will never lose its relevance. On the other side, online contagion can be encouraged by e.g. social media companies who apply epidemiological knowledge to viral marketing and the never-ending battle for your attention. This has a darker side too, ranging from echo chambers and online manipulation to the privacy concerns of many citizens about the amount and nature of data harvested by these companies.

Of course, you cannot talk about technology without touching on computer viruses, and Kucharski is equally capable of writing engagingly about computer viruses and worms, malware, botnets, DDoS attacks, or the danger of poorly secured devices that are forming the Internet of Things (see also the forthcoming Crime Dot Come and my review of Industry of Anonymity). Or what of the little-known habit of programmers to borrow pieces of code for online applications that all need to be called on, creating a vulnerable chain of dependency? This chapter might at the outset feel like a digression. But Kucharski beautifully circles back to the topic at hand by showing the parallels between virus evolution in both living and artificial systems. It is a neat writing tactic that crops up several times.

“One particular example that made me squeal with delight was how phylogenetics […] can be applied to […] the history of folk tales.”

More eye-opening for me was the long history of applying epidemiological ideas to public health. The spread of violence, riots, even suicide, can be studied and understood in this framework. One topic that made me squeal with delight was how phylogenetics (the study of evolutionary relatedness by identifying common ancestors) can be applied to a completely different field such as the history of folk tales.

From the above, it is clear that, next to disease outbreaks, The Rules of Contagion ricochets off a huge number of topics. Not all of these will interest everyone, but the enthusiasm with which Kucharski covers them is tangible, and the universal relevance of the epidemiological rules striking. Some of his metaphors are particularly lucid. Of models, he writes that they are “just a simplification of the world, designed to help us understand what might happen in a given situation […] particularly useful for questions that we can’t answer with experiments“. While of the difficulty of applying phylogenetic analysis to a slowly evolving pathogen, such as measles, he writes it is “a bit like trying to piece together a human family tree in a country where everyone has the same surname“.

“[…] of the difficulties of understanding the spread of a pathogen that evolves only slowly […] he writes it is “a bit like trying to piece together a human family tree in a country where everyone has the same surname“.”

The timing of publication of this book was uncanny, right as the COVID-19 pandemic started ramping up around the world. This presents both a blessing and a curse. On the one hand, there is a sudden, huge interest in the topic of epidemiology, and the publisher has understandably been keen to emphasize this while marketing The Rules of Contagion. On the other hand, its publication in March 2020 meant that the writing for it will have finished when the pandemic was but Chinese whispers on the wind.

Given the urgency with which people now want accessible information, many will come to this book with a narrow focus of interest and might end up frustrated or disappointed with what they see as too many irrelevant asides. Some Amazon reviews suggest this has already been the case. Personally, I think this is both unfair and misses the point. One only has to look at Kucharski’s Twitter feed to see how involved he is with the ongoing pandemic. If he had finished writing it later, would it have been a different book? I would not be surprised if the paperback* will contain a new introduction or post-script. Or Kucharski might follow Quammen’s example. A year after Spillover was published he excerpted and adapted part of it at the start of the 2014-2016 Ebola outbreak.

Whatever Kucharski will do next, here is a writer to keep an eye on. The Rules of Contagion is an incredibly engaging piece of cross-disciplinary popular science that will hold its relevance well beyond the COVID-19 pandemic.

* Update February 2021: Having leafed through a copy of the UK paperback, I can confirm that Kucharski has chosen to update some sections of his book to reflect the events of 2020.

Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.

The Rules of Contagion hardback, paperback, ebook or audiobook

Other recommended books mentioned in this review:

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Some books, it seems, sit on your shelf just waiting for the right moment. David Quammen’s Spillover may have been published back in 2012, but it eerily foreshadows the 2019-20 coronavirus pandemic that currently keeps the world in its grip, and provides many insights. Right now, most people are of course concerned with the direct impact on public health and their jobs. While we try to slow down the spread of this disease, the global economy is taking a nosedive as country after country goes into lockdown. Once we come out on the other side though, there will be deeper questions to be asked. Could this happen again? How do we prevent that? And what the actual fuck just happened? Let Quammen be your guide, for, as he will show, everything comes from somewhere…

Spillover: Animal Infections and the Next Human Pandemic, written by David Quammen, published by Vintage in August 2013 (paperback, 592 pages)

Quammen likes to write big, chunky books. Spillover tops out at 587 pages. But do not let this put you off, for he is a master at writing a suspenseful narrative and has chopped up the book in 115 short chapters that irresistibly flow into each other.

He kicks off with the pandemic that wasn’t. You can be excused for never having heard of Hendra. First recognized in Brisbane, Australia, in 1994, it killed a dozen horses and one man. After months of research, it was traced back to bats. This crossing of species boundaries by infectious diseases is at the heart of Spillover and is a phenomenon known as zoonosis (professionals will want to refer to Zoonoses).

Zoonosis leads on to the second important concept in this book: reservoir hosts. The reason viral diseases such as polio and smallpox no longer plague us is that they only occur in humans. With nowhere else to hide, they can be eradicated by sustained vaccination campaigns. Zoonoses, in Quammen’s words, are more like guerilla fighters. They strike unexpectedly and disappear again, sometimes for years, while living on in other organisms where they cause little harm. Tracking down these reservoir hosts requires intrepid individuals willing to leave the confines of their laboratory. Several such virus hunters have written about their adventures.

“[…] the second important concept in this book: reservoir hosts. […] Zoonoses are more like guerilla fighters. They strike unexpectedly and disappear again, sometimes for years. But where do they go?”

Quammen spares no effort and accompanies many such scientists in the field, specifically to learn more about Ebola. The bloody details of this disease have been slightly exaggerated in the (in)famous book The Hot Zone (Quammen provides a healthy corrective). But it still is a horrific disease that stalks Africa, periodically popping up in humans but also killing many gorillas. The hunt for its reservoir host continues, although bats are a likely candidate. Quammen’s vivid and personal descriptions of the fieldwork, the extraordinary working conditions, and the chance scientific breakthroughs are what make Spillover such a pleasant mix of popular science and reportage. It is worth noting that at the beginning of the 2014 Ebola outbreak, a part of Spillover was updated and republished. It was a bit premature in hindsight, as that outbreak lasted until 2016.

Of course, a large part of virological research plays out in the lab, and Quammen shows himself equally at home here. The long chapter on AIDS and HIV is a perfect example, describing the decades-long research effort that has pushed the emergence of this disease back in time, all the way to the start of the 20th century. At the same time, the family tree of HIV has exploded “like an infectious starburst”, and Quammen skillfully guides the reader down the warren of HIV-1 and HIV-2, the different groups within these, and, nested within those, the many subtypes. Oh, and of course the numerous variants of the closely related simian immunodeficiency virus, or SIV, found in apes and monkeys. He relies on interviews and close reading of publications to reconstruct the tumultuous and twisting history of scientific breakthroughs and blind alleys.

Quammen also shines when it comes to memorable metaphors and masterful distillation of technical details. All of this is helped by crisp writing, short and straightforward sentences, and the repeating of salient points. He knows the details are complicated, yet he enlightens you in a conversational tone without ever being condescending. He is equally at ease giving you a potted history of the important epidemiological parameter R₀, as he is highlighting the unique character of retroviruses such as HIV. The former is the basic reproduction number that you will have seen in the news lately.

“There is some eerie foreshadowing when Quammen asks: “Will the Next Big One come out of a rainforest or a market in southern China?” […] once we get out on the other side, there will be some uncomfortable and probing questions to be asked.”

Particularly relevant now is the distinction between DNA and RNA viruses, coronaviruses belonging to the latter. As highlighted in my review of Viruses, single-stranded RNA lacks the error-correction mechanisms of DNA and is thus much more prone to mutation and rapid evolution. Quammen throws three metaphors at you to emphasize this point before repeating it: “RNA viruses mutate profligately“.

A host of other, lesser-known diseases fills these pages: herpes-B, Nipah, Marburg, bacterial zoonoses such as Lyme disease, psittacosis, and Q-fever. Even a surprise zoonotic strain of malaria. After all, most strains of malaria are vector-borne diseases, mosquitoes being their vector. They are incredibly deadly, but they are not zoonoses.

All of these have fascinating backstories. But one point jumped out at me in particular: bats. Bats are, or are suspected to be, the reservoir hosts of many zoonoses. Why? Quammen highlights some of the unique aspects of their biology that might contribute to this: there are many species (a little-known fact is that about 20% of mammal species are bats!), they roost and hibernate at extremely high densities, and they fly. For more, see Bats and Viruses, Bats and Human Health, and the practical FAO manual Investigating the Role of Bats in Emerging Zoonoses.

“Many will have been left bewildered by the abrupt arrival of the current coronavirus pandemic. To better understand the world that has just gate-crashed ours, Spillover is (still) a magnificent piece of science reporting”

Viruses are everywhere: some speak of the virosphere rather than the biosphere, while Carl Zimmer calls ours a planet of viruses. Of the Ebola virus, Quammen writes that it “is not in your habitat. You are in its.” And the virosphere is a Pandora’s box that we have ripped wide open through our actions. A recurrent and important message in Spillover is how habitat fragmentation and destruction exposes us to a menagerie of new viruses as wild animals are forced to live and die in our midst.

Particularly fertile breeding grounds for zoonoses are the bushmeat trade and the so-called wet markets in Asia where a wide range of poached animals are traded and slaughtered. Nuwer’s Poached highlighted the exotic tastes and conspicuous consumption by wealthy diners as one of several driving forces behind the demand for wild meat. These markets were ground zero for the SARS outbreak in 2002-03, and likely too for the current coronavirus pandemic. There is some eerie foreshadowing here when Quammen asks: “Will the Next Big One come out of a rainforest or a market in southern China?” As I said at the beginning, once we get out on the other side, there will be some uncomfortable and probing questions to be asked.

COVID-19 is only the latest in a long line of zoonotic diseases, and will certainly not be the last. But rather than wanting to make you more worried, Quammen wants to make you more smart. Many will have been left bewildered by the abrupt arrival of the current coronavirus pandemic. To better understand the world that has just gate-crashed ours, Spillover is (still) a magnificent piece of science reporting that weds exceptional clarity to spell-binding storytelling.

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Other recommended books mentioned in this review:

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