By Major Andy Forney
The other day, while at the gym, I had the unique experience of viewing CNN’s frontal assault-style coverage of Ebola in the United States. Talking heads, all looking very serious, discussed the prospects of the disease’s transfer among the general public, oftentimes framed with a odd red, white, and blue tinted microscopic image of the virus. The gym had thankfully muted the sound, but the baleful pictures and serious looks seemed to be pulled from a “how-the-zombie-apocalypse-started” montage from the latest horror movie. I wondered briefly if the Ebola patient in Dallas had somehow managed to be on the missing Malaysian plane from last summer. And, from my perspective, such coverage seemed to be working; I witnessed at least two customers at my local brick-and-mortar commercial bookstore holding copies of Richard Preston’s The Hot Zone in just thirty minutes.
It is not that The Hot Zone is a bad book, or that the experts on CNN do not possess the background to discuss Ebola. Rather, both Preston’s book and cable’s news coverage do not allow those attempting to formulate a strategic response to the Ebola crisis at home, and more importantly in Africa, to think dispassionately about their subjects. The United States appears to be groping towards setting a precedent for using elements from the entire DIME spectrum to respond to pandemic threats. And for the first time, military force looks to become the primary factor in the U.S. response. Strategists, military and civilian alike, now face the daunting task of crafting a strategy that most effectively stops the viruses spread, and then sets the conditions to preclude or limit future pandemic-size outbreaks.
In this light, what are the best books to read about epidemics, society, and strategy? Frankly, no one books answers these questions. The Hot Zone provides a page-turning read with a nice account of Ebola’s first outbreaks, its morphology, and dramatizes its future spread, but does not place the virus adequately within a joint/inter-agency response campaign. As I looked through my bookshelves, I gravitated to a handful of books that I think best illustrate two central themes we must consider as we look at disease in modern world history: first, how disease and epidemics can quickly destabilize societies and cultures and have real-world strategic impacts; and second, how quickly epidemics and their responses become politicized.
McNeil comes from “disease in history” nobility; his father, William H. McNeil, wrote the classic Plagues and Peoples. McNeil the younger foregoes the epoch-spanning narrative of his father and instead focuses on how diseases, specifically yellow fever and malaria, came to decide the course of empire in the Greater Caribbean Basin. These two diseases existed endemically within the Caribbean, and as empires attempted to project power with non-immune military forces into the region, they provide a ready-made population for either of the diseases to flare up. These flare ups, be it outside Havana, within the siege works of Yorkton, amidst the invasion of Haiti, or in the revolutionary Yucatan, decided the geo-strategic course of events in a given conflict. Anyone that questions the importance of crafting an adequate strategic response to epidemics must read McNeil’s book.
The Coming Plague: Newly Emerging Diseases in a World out of Balance by Laurie Garrett
Many readers initially overlooked Garrett’s book, first published in 1994, as attempting to ride the wave of popularity brought about by The Hot Zone. This is an unfair characterization; The Coming Plague addresses many more issues beyond Ebola’s appearance during the late-Cold War era. Specifically, Garrett tapped into a very 1990s theme, globalization, to explain why diseases previously contained to secluded areas would soon appear in previously far-off locales. The recent article in Science that traces the evolutionary birth of HIV serves as further evidence of her claims. At the same time, the decline of biodiversity resulting from increased deforestation and urbanization, increased population migrations due to severe weather and political instability, and the lack infrastructures to respond to new epidemics all contributed to “thirdworldization,” the decline in adequate civil structures that typically lead any public health response. Garrett revisited this theme in her later book, Betrayal of Trust, an account of the defunding and hamstringing of global public health organizations. The themes outlined by Garrett have only grown worse over the two decades since her book’s publication. Any strategic response to epidemic diseases requires a comprehensive look at systems within an afflicted country, as well as a retooling of global health responses. The latter should prove a far more difficult proposition.
The Great Influenza: The Story of the Deadliest Pandemic in History by John M. Barry
America’s Forgotten Pandemic: The Influenza of 1918 by Alfred W. Crosby
Although a wave of books arrived over the last decade dealing with the 1919 influenza epidemic, the above two best address the outbreak, one very readable (Barry) the other the academic classic (Crosby). Both Barry and Crosby explore the social schism created by the influenza pandemic. Disease, beyond any other natural catastrophe, possesses the most potential to rend the social fabric. Epidemics breed fear of the “other” and others. Again, the intense population movements inaugurated by World War I (Barry blames the U.S. mobilization effort), created the necessary conditions for influenza to first spread, and then to create a global conflagration. Readers should find striking the U.S. response: quarantine, forced seclusion, and government support to the scientific and medical community. Future scenarios would most likely entail similar methods, leading one to wonder, how do we encourage and/or support these practices in partner nations?
The Cholera Years: The United States in 1832, 1849, and 1866 by Charles E. Rosenberg
And the Band Played on: Politics, People, and the AIDS Epidemic by Randy Shilts
Both of these books mark the departure from response, per se, to the politics of disease. It is striking that over the course of the 150 years these books encompass, from cholera to AIDS, politicians uniformly wielded the fear and paranoia engendered by disease as an electoral weapon. Rather than creating new social phenomena, epidemic outbreaks tend to reinforce conservative aspects of the cultures they occur within. Andrew Jackson called out the new “shiftless” urban workers that suffered from cholera in the 1830s much as the latter generations blamed the “unclean Irish” and the “immoral gays.” The advent of germ theory did little to deter this practice into the twenty-first century. The social isolation created by an epidemic reinforces an “us-vs.-them” mentality that, again, tends to appeal to conservative or fundamental conceptions of the social structure. It would not prove a stretch to suppose that post-Ebola West Africa may prove increasingly susceptible to the spread of fundamentalist Islam from the Sahel or to the genesis of genocidal factions.
Planet of Slums by Mike Davis
Not directly about disease or epidemics, Davis’ book charts the rise of urban slums throughout the globe. Slums provide a unique problem to disease response; often formed outside the purview of official civil control or regulation, it is nigh impossible to either count the population within them nor provide essential services in case of disaster. Public health officials believe that that the current West African outbreak could last for 12-18 months, mainly due to the arrival of the disease in the shantytowns of the affected nations. The lack of civil infrastructure in these areas means that diseases can fester within the periphery of West Africa cities, allowing hundreds to die prior to alerting public health officials. People tend to gravitate towards those unofficial groups that appear within the slums that provide an element of order and infrastructure, be they schools, clinics, or security forces. As such, the unofficial elements that provide a ready response can gain a level of legitimacy that the official governmental response can only strive to find. This not only can destabilize the nation-state, but also create a chaotic environment as support elements attempt to identify those actors that have the most impact at the local community level.
What do these books teach us about crafting a strategic response to an epidemic? First, controlling population movement is a key first step; the heavy handed public quarantine in Sierra Leone exhibits the issues with this strategy. Second, the afflicted area is ripe for future dissent, radicalization, and violence. Any response must be prepared to react to these contingencies and craft an information campaign that focuses on inclusion and healing. Also, any effort to create a successful response necessitates building partner capabilities, but beyond just the military or security sector. Stressed and/or collapsed civil infrastructure will need reinforcement to avoid further political atrophy. Most importantly, the United States must view any strategy as a political response that builds up our partners politically. Ebola will create new political realities within each of the afflicted West African nations that could allow for rapid and traumatic destabilization. Any response must emphasize moderation and inclusivity from our partners. Stop gap measures that emphasize “boots on the ground” over a thoughtful strategic response will not fundamentally change the conditions within the Ebola-infected region, nor will it make the United States any more ready to respond to future crises.