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We’ve All Just Had A Crash Course on Pandemics

I’ve gathered up all the best books on epidemics so we’re clear on what’s going on here…

All the work I do in public health is to create a stronger and more responsive health system. But I had no idea what a pandemic would look like, or what it would mean for health workers. But, I had heard that the Ebola virus had convinced Bill Gates to invest in health systems (rather than vertical interventions), so I knew epidemics could be instructive.

Living through COVID-19 is an education. But, what are we supposed to be learning? To help us public health professionals make sure we are adding to our work toolkit, I’ve quickly read & summarized some key books around epidemics – along with colleague Ruchi Dixit.

What are the key lessons? I think the main one is the specificity of each pandemic. But there’s a few global lessons as well; the importance of an ecological health; patient communities being involved in research agendas; and strong health systems. Let me know if I’ve missed anythin here.

We can tell this book is relevant to the current moment, because it features some of the same characters as the COVID-19 response. Dr Fauci also led the federal government’s response to HIV. In this book, he is the bad guy who holds up drug research, making treatment inaccessible. This is both an oral history and first-person account of the early years of HIV in New York city, from trying to solve the mystery of what the weird new “gay disease” was, to the campaign for treatment, to the transformation of HIV into a chronic non-communicable disease through ARVs. The book describes the essential role of community activism in pushing forward the HIV research, prevention and treatment agenda, to make sure that at-risk-populations and patients were always part of the research dialogue. In fact, one of the main organizations, the Treatment Action Group, is now working on COVID-19. But more importantly it describes how important community is for survival when going through the trauma of so much illness. This is excellent writing, and there are great stories and characters within this movement. Compelling but not a quick read at 1000+ pages, worth taking time over.

This book takes over from “How to Survive a Plague” which winds up its story in the mid-90s. From the mid-90s onwards, there was a huge and well-resourced global HIV industry, and this is what Elizabeth Pisani writes about – when the money started flowing in. Her career trajectory and the world she describes is very familiar – crunching numbers, writing reports, and lots of time spent in airports.

This book is an exploration of the utility of mathematical models to understand the spread of viruses, ideas, political movements and financial trends. He takes up the journey of Ronald Ross, the Nobel Laurette for his work in understanding Malaria transmission. He argues that ‘herd immunity’ rather than eliminating mosquitoes completely is the way to drastically reduce malaria spread- basically the ‘R’ number (reproduction number- the number of people one infected person can spread the disease to). In the current context, the R number of Covid 19 is between 2- 3, and it needs to be below 1 to control the contagion. However, he also highlights the specificity of each pandemic. The book mentions in the beginning itself- “If you’ve seen one pandemic, you’ve seen … one pandemic.”

In this book Quick encourages us to set the seemingly impossible goal of eliminating epidemics, with seven steps he calls the “power of seven”: (1) ensuring bold leadership at all levels; (2) building resilient health systems; (3) fortifying three lines of defense against disease (prevention, detection, and response); (4) ensuring timely and accurate communication; (5) investing in smart, new innovation; (6) spending wisely to prevent disease before an epidemic strikes; and (7) mobilizing citizen activism.

He also goes through some of the likely sources of a new pandemic; industrial farming, bioterrorism, lab mistakes (gene manipulation), and the multiple costs (slowdown in economic activity, health care expenses, insurance, losses in agriculture). He makes a strong economic case – that “a very modest annual investment of $1 for each global inhabitant will return $3 to $10 in savings.” An excellent plane read.

This book described the increasingly common occurrence of diseases moving from animals to humans. Quammen describes the planetary ecology of diseases and viruses, through different “spillover” events from all over the world – where a disease jumps from an animal to human – often through another “amplifier” animal. It is very current seeing as COVID-19 was passed on the humans from bats, then to pangolins and then to humans, probably via a wet market. Why is this happening at such frequency? “Human-caused ecological pressures and disruptions are bringing animal pathogens ever more into contact with human populations, while human technology and behavior are spreading those pathogens ever more widely and quickly.” This book is well written and helpful for understanding the larger ecological context of diseases.

The story of turning back HIV is one of India’s big public health success stories, and Ashok Alexander was at the centre of it as the lead of the Gates Foundation’s Avahaan program. I enjoyed reading this book because I know many of the people in it – and it’s great to see their hard work immortalized. It’s also important because it tells the story of reaching out to the most marginalized sectors of the population, and realizing that their health status is caught up in their social marginalization. To address their health needs you also need to address the violence they experience, their social isolation, and their poverty. The HIV epidemic bought the social dimension of health to the forefront of our minds, and we should never forget it.

This is a great read about how in 1854 John Snow used maps to discover the cause of cholera in London – the Broad street communal pump. It’s a detective story, but also a great exploration of how health and geographies intersect. It describes how the population density of cities nurtured a cesspit of disease until the development of modern sewerage systems. Once there was proper water and sanitation cities could become centers of creativity, innovation and cosmopolitanism, as opposed to disease. Too often we think of health as about doctors and nurses and care providers – this book reminds us that at the core of good health is a proper water and sanitation system.

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