Two books about diseases and public health

I’ve mentioned a few times that my research focus during my MA was disease (specifically rabies) and the Victorian novel. I’m still very interested in diseases in general, especially how we construct narratives of disease and how these narratives—often deeply ingrained—influence our ideas about public health. Old (research) habits die hard: whenever I see a new cultural history of disease come out, I buy it. And that’s how I came to have Eula Biss’s On Immunity and Steven Johnson’s The Ghost Map sitting unread on my shelf. I packed both for a vacation last month. I know, I am great at picking beach reads.

As its title suggests, On Immunity is an examination of the idea of immunity. Biss was inspired to write the book after she had a baby and faced the question of whether or not to vaccinate him. Biss did vaccinate her son, as she had always thought she would, but she was surprised by the amount of fear she felt herself, and encountered in others, when she talked to other mothers about this choice. She started thinking about vaccination, and the idea of immunity, and how vaccines developed in the first place, and this strange cultural moment we live in where people are opting out of vaccines that have saved literally millions of lives in the past hundred years. (I’m wildly pro-vaccine, in case that wasn’t clear before.)

In On Immunity, Biss interrogates the metaphors and myths we use to describe immunity. Vaccination is an expression of fear, whether it is fear of something concrete and relatively preventable such as death by measles, or something far more intangible, such as the fear of death itself. But the anti-vaccination movement is also based on fear: fear of the government, fear of Big Pharma, fear of injecting the unknown into your body. If skin is a barrier between our bodies (our selves?) and the outside world, then vaccination penetrates that barrier—all in the name of granting you immunity.  It does seem contradictory, doesn’t it? After all, vaccines contain the very viruses they are supposed to be protecting us from. The earliest form of inoculation against smallpox involved rubbing scabs or fluid from a smallpox patient into one’s own skin.

Biss understands this fear of vaccines on an individual level, but she also points out that in the case of infectious disease, our bodies may not be solely our own. Herd immunity, which means the general immunity to a particular disease in a population of people, depends upon people getting vaccinated. As the recent resurgence of diseases like measles shows, it only takes a few nutty people to threaten herd immunity for everyone. And there are people who can’t be vaccinated for health reasons (ex. allergies) or who have compromised immune systems (ex. cancer patients). What is our responsibility to public health? Are we required to be vaccinated so that others won’t get sick? Health is assessed on an individual level at our yearly physicals, but our own physical health depends in many ways upon the health of our community, especially when it comes to infectious diseases.

Victorian London learned this the hard way during the 1854 Broad Street cholera outbreak. Cholera was the scourge of the 19th century, popping up every so often and routinely killing thousands of people per outbreak. (Cholera is still a problem today.) No one knew how it was spread until the Broad Street outbreak, but there were plenty of theories, chief among them the miasma theory. Simply put, back then, London stank. Lots of people crammed into tiny dwellings leads to lots of waste, and Victorian Londoners weren’t so great at managing their sewer system (or, um, having one). The air in London smelled pretty bad. Many respected officials and doctors believed that diseases, including cholera, were spread by this “bad air,” aka the miasma theory.

Along came John Snow, a doctor who was already notorious for pioneering the use of anaesthesia. When an outbreak of cholera occurred in his neighbourhood in Soho, he mapped the instances of disease and traced them all back to one water pump, where he found that the water supply had been contaminated by one household suffering from cholera. Feces from that household made its way into the water supply, and the disease spread through the water supply into the surrounding houses with devastating effects. Snow was one of the first epidemiologists, although he never got the credit he deserved and died without having his theory accepted by the medical establishment of the day.

The Ghost Map tells the story of this outbreak and Snow’s investigations. It is well-researched and fascinating, like a thriller where the villain is invisible and also causes a lot of diarrhea and suffering. I wish, though, that Johnson had spent more time investigating the cultural context of cholera and how Victorians thought about disease. The idea of the social body is an important one to add to this discussion, especially because it still has relevance today (see Biss’s questions about whether we owe it to our neighbours to get vaccinated). And how did Victorians approach infectious diseases like cholera, tuberculosis, and typhoid fever?  How did they write about disease in their newspapers, depict it in cartoons, confront it in their fiction? They had limited medical knowledge of pathogens and germs, but they were beginning to break through in other important areas (microscopes, the idea of inoculation). It seems to me that this conflict gave rise to many inaccurate but interesting depictions of diseases that suggest a society obsessed with health, illness, and infection. The Ghost Map could have benefited from some discussion of these questions.

In some ways, we’re still Victorians. Just like them, we’re obsessed with health. Also like them, and other humans throughout history, we still infuse our disease-related language with metaphor. As Biss points out, the way we talk about many diseases is steeped in the language of battle: so-and-so “lost her battle with cancer,” white blood cells are “armies” that keep our bodies safe from infection. In our struggle to understand our bodies, we rely on metaphor to give shape to our invisible inner workings. As Susan Sontag argues in Illness as Metaphor (a must-read for anyone interested in these issues), our dependence on metaphor leads to moral judgments about certain diseases. Sontag looks at consumption (tuberculosis) in the 19th century and cancer in the 20th and concludes that our disease metaphors lead to a kind of blame the victim mentality. For the Victorians, all kinds of diseases could blamed on emotional repression or moral failings. Countless novels feature women who are forced to bury their feelings and are soon wasting away from some nameless ailment. Men in the same novels who are “weak” and prone to drink inevitably end up dying of their own unnamed illness. And not a lot has changed in how we talk about illness. In 1978, when Sontag wrote Illness as Metaphor, one alternative cancer treatment involved psychotherapy to help find out what part of your personality brought cancer upon you.

Likewise, our current obsession with trends like “clean eating” often leads us to assume that people who don’t eat chickens that were raised to believe in themselves and organic blueberries watered with angel tears are doomed. There is, of course, a lot of privilege involved in these assumptions we make about health and wellness. The point is, a disease is never just a disease.  It’s a battle we must fight. It’s a statement about our incomes, the food we eat, the amount of exercise we get, the kind of sex we have or the number of partners, the amount of alcohol we drink. It’s a sign of our most private defects, writ upon our bodies for the whole world to see.

And why do we think about disease this way? I don’t know, but I suspect it’s because we have a hard time accepting that our bodies are, ultimately, out of our control. We can eat all the happy chicken we want and avoid pesticides and wear a mask on the subway, but we’ll still get sick, especially if we live in large urban centres (and increasingly, many of us do). There are precious few things we can control about our bodies. All the more reason to get vaccinated.