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‘Pandemic,’ by Sonia Shah

Louitesse Cineas of Haiti, who prepared for burial the first victim of the 2010 cholera epidemic.Credit...Damon Winter/The New York Times

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Over Christmas, headlines across Britain screamed that Victorian-era diseases had returned. The past five years had apparently witnessed a 136 percent increase in scarlet fever cases, a remarkable 300 percent rise in the confirmed ­cases of cholera along with reported occurrences of other once-vanquished diseases like tuberculosis, measles and whooping cough.

The 300 percent jump in cholera cases is especially troubling — that deadly microbe devastated England nearly as much as the plague, claiming thousands of lives, especially in London. And the disease happens to be making its mark all over the world today, from ISIS-controlled territories in Syria and Iraq to Cuban prisons.

Having appeared only in Bengal, cholera made its first pandemic leap in 1817, during British rule in India. Two centuries later, it is in its seventh pandemic. The microbe’s most horrible 21st-century toll continues to unfold today in Haiti, where Vibrio cholera was unwittingly introduced by Nepali United Nations peacekeepers bivouacked alongside a river tributary after the 2010 earthquake. Water systems across the nation were soon contaminated with the bacteria passed in human waste, leading to a breathtaking cumulative 745,558 diagnosed cases of the disease by July 2015, causing 8,972 deaths.

Though the cause of cholera is known and its treatment is well understood and inexpensive, efforts to contain it are often stymied by politics, poor planning or poor infrastructure. From the moment cholera appeared in Haiti in 2010, its control became fodder for intractable public health disputes, allowing the microbe to spread unchecked. The outbreak that threatens millions of refugees and people living in disputed territories in Syria and Iraq and in neighboring nations is fueled by man-made disasters like war coupled with El Niño ocean-warming events, which may spread the bacteria and be especially intense in 2016 thanks to climate change.

Given these developments, I eagerly anticipated Sonia Shah’s “Pandemic.” Cholera is the spine that runs through her tour of global contagions, and I hoped Shah would deliver the historical, biological, political and social perspectives on the disease that she brilliantly exhibited in her book on malaria, “The Fever.” Like John M. Barry’s spectacular “The Great Influenza,” Shah’s previous book took readers on a long, research-rich journey through the historic struggles between mankind and one of its great scourges.

Sadly, “Pandemic” has no clear focus, and it is not the much-needed definitive analysis of cholera I hoped it would be. It tries instead to cover every single major outbreak of recent history, from the 2003 SARS epidemic to Shah’s own battle with MRSA (methicillin-resistant Staphylococcus aureus), adding little to the large canon of outbreak and emerging-diseases literature that stretches from Paul de Kruif’s masterpiece “Microbe Hunters” (1926) to my “The Coming Plague” (1994), Jaap Goudsmit’s “Viral Fitness” (2004), David Quammen’s “Spillover” (2012) and The New York Times’s Pulitzer Prize-winning reports from the 2014 Ebola epidemic in Africa.

This canon combined with the deep trove of scientific publications on the topic prompts the question, Why another book? Shah struggles with the question herself. Should she dive into the history of a pathogen, she asks herself at the start of her investigation, or profile a nascent one? She finally finds a solution in a speech given by the microbiologist Rita Colwell. Colwell refers to the “Cholera Paradigm,” which states that all of the factors inherent in disease emergence and spread can be explained by studying just one microbe, Vibrio cholerae. Shah structures her book accordingly, weaving back and forth from cholera to other newer viruses and bacteria, visiting cities in China, India and Haiti that were once the sites of outbreaks. “Today, as we stand on the cusp of the next pandemic, the multistage journey from harmless microbe to pandemic-causing pathogen is no longer invisible,” she writes. “Each stage can be laid bare to see.”

Much of the literature on contagions appeared at a time when the war on infectious diseases was far from won and the idea that human behavior could promote the emergence of previously unknown pathogens was deeply controversial. That is no longer the case anywhere in the world. Doctors and public health specialists in countries as wealthy as Japan and as poor as Papua New Guinea now share strong concerns about the waning efficacy of antibiotics amid rising drug resistance. Outbreaks now emerge with such gravity and frequency that SARS, Ebola, swine flu, H5N1 influenza, XDR-TB, NDM-1 plasmids, E. coli 0157:H7, Zika and dozens of other frightening microbes are regarded as national security threats. The multibillion-dollar Global Fund to Fight AIDS, Tuberculosis and Malaria was established after the 2000 G8 Summit in Japan, and in almost every G8 (now G7) summit since, disease treatment, surveillance and control have regularly been on the agenda. Last year Chancellor Angela Merkel of Germany and President Obama called for a multibillion­dollar health-security initiative aimed at bringing all of the nations of the world up to high technical standards for disease detection and response.

Either Shah is not aware of the international drama unfolding at this level or she chooses to ignore it. She doesn’t investigate why all but 48 nations of the world refuse to abide by the epidemic surveillance principles of the World Health Organization’s International Health Regulations. Nor does she delve into why both the G7 and G20 efforts have largely failed to concretely address global vulnerabilities to old diseases like cholera, or new ones such as SARS. She makes no mention of the enormously important 2015 Gesundheitsministertreffen G7 pact to fight antibiotic resistance, control microbial disease and reform the W.H.O. post-Ebola.

Instead, Shah offers a sort of TED talk list of technological quick fixes for identifying outbreaks in their early stages. But no technological tool kit or team of disease detectives can protect humanity from the rising tide of new microbial diseases, or newly evolved and drug-resistant older scourges. As Shah demonstrated in “The Fever,” the tools of malaria prevention, such as curative drugs and bed nets, are useless unless a global political and financial will is in place to facilitate their distribution in poor countries and the recipients put the devices to proper and consistent use. She doesn’t ask why the W.H.O. maintains a stockpile of only one million ­doses of the cholera vaccine (although it’s expected to double this year) or how it decides which populations should receive precious supplies.

And in an otherwise detailed section on the cholera outbreak in Haiti, she doesn’t dissect the disagreement between medical advocates, like Dr. Paul Farmer at Harvard, and environmental activists over how best to tackle the epidemic. Farmer, who worked closely with former President Bill Clinton on the Haitian earthquake response, focused on a medical approach to cholera control: vaccination and treatment. In contrast, French public health experts working in Haiti tracing the Vibrio’s spread said the microbe had exploited a water system that was already known to be a major source of child illness and death. Fixing the water and sewers never garnered the technical and financial resources necessary, and cholera is now a permanent feature in impoverished Haiti.

More seriously, Shah doesn’t examine the failures to implement disease surveillance and epidemic control. Five high-level assessments have been ­completed regarding the performance of the W.H.O. and other global institutions in the recent Ebola outbreak in Liberia, Sierra Leone and Guinea. Each concluded that a litany of errors allowed the disease to spread for months before the W.H.O. declared a state of global emergency and any significant assistance from the rest of the world arrived in the West African nations. Between 2013 and 2015, there were 28,637 ­reported cases of Ebola, and 11,315 people died. Thousands more were sickened before American and British soldiers and humanitarian aides arrived, bringing more than a billion dollars’ worth of supplies and equipment.

Shah’s discussion of solutions too often reads like a boilerplate list of technocratic fixes that have been much discussed or, worse, debunked. She writes of a “global immune system” of technology and surveillance that “could detect ­pandemic-worthy pathogens before they hop on flights and get swept up in population movements, pinpointing the next H.I.V., the next cholera and the next Ebola before they start to spread” and could be funded by a 1 percent tax on air travel. The Ebola experience demonstrates that she is wildly wrong: In March 2014, the Pasteur Institute in Lyon, France, correctly identified Ebola as the cause of the then-small African outbreak. A standard tool kit of case detection and high-tech lab tools was applied to hunting down cases. By the end of April 2014 the W.H.O. and its advising experts from all over the world were convinced that Ebola was vanquished, but they were horribly mistaken.

Saving humanity from microbial threats will require far more than the social-media searches, satellite sweeps, “hot spot” surveillance teams and similar solutions Shah proffers. Nothing short of an international commitment to full implementation of the International Health Regulations, coupled with provision of basic health care to all and an all-out scientific R & D effort to develop rapid point-of-care diagnostics, treatments and vaccines will be sufficient. Such a scale cannot be ­funded by an airplane tax — a system that is, by the way, already in place in the form of Unitaid, funding some H.I.V., tuberculosis and malaria care in poor countries.

When Shah focuses on a single epidemic — as she does with cholera in the chapter titled “The Cure” — her skills as a historical investigator shine, and we are left hungering for more. She brings fresh insights to the century-long battle inside the European medical community over the cause and the treatment of the disease, which swept periodically through London, Paris and countless other European and North American cities. In pages as riveting as any thriller, Shah describes pitched battles between the dominant “miasmatists,” who believed the smell of human waste caused the illness, versus the British anesthetist John Snow, who was convinced that cholera was caused by contaminated waters — and perhaps traceable to one water pump. Snow died while trying in vain to defend his theory to the British Parliament, and miasmatists so dominated thinking throughout the 19th century that Londoners deliberately filled the Thames with human waste during cholera outbreaks to distance themselves from the fumes they believed caused the disease.

By the 1860s, the German chemist Max von Pettenkofer led medical perspectives on the disease, refuting John Snow’s contaminated-water hypothesis in favor of “poisonous clouds.” Even when the German microbiologist Robert Koch announced in 1884 that he had discovered the pathogen responsible for the disease, Pettenkofer and the miasmatists clung to their “smelly air” views and held sway over politicians and governments. It was only when cholera returned to Germany in 1897, killing residents who drank from the deliberately contaminated river while sparing those who drank filtered water, that the miasmatists backed off.

Now, this is storytelling — a narrative that evokes both the power of the disease and the power of human folly. Had Shah devoted herself to telling us more about the arc of human understanding and battle with cholera, rather than superficially rehashing the existing literature, “Pandemic” would have been riveting to read and an invaluable contribution to public health.

PANDEMIC

Tracking Contagions, From Cholera to Ebola and Beyond

By Sonia Shah

271 pp. Farrar, Straus & Giroux. $26.

Laurie Garrett received the Pulitzer Prize for her coverage of the 1995 Ebola epidemic in Zaire and has written numerous books on emerging diseases and global health. She is a senior fellow for global health at the Council on Foreign Relations.

A version of this article appears in print on  , Page 12 of the Sunday Book Review with the headline: Killer Germs. Order Reprints | Today’s Paper | Subscribe

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