DREAD- How Fear and Fantasy Have Fueled Epidemics From the Black Death to Avian Flu
Public Affairs Books, 2009
DREAD is a fascinating look at how humans have reacted to epidemics throughout history. Written at a time when society’s fear of swine flu was at a peak, Philip Alcabes presents a cogent argument that policy-makers, physicians and the public must avoid fear and imagination in dealing with epidemics, and instead focus on facts and action.
It is clear that we use the term “epidemic” loosely today, describing the “obesity” epidemic, or the “epidemic of untreated diabetes”. While these are serious conditions, the public can lose focus on what the term really conveys- the sudden appearance of disease or forces that catastrophically kill large segments of the population. Separating out fact from fiction, political agenda from medical certainties, fear from a frontal intervention, is the goal of Alcabes’excellent book.
Alcabes focuses on the physical events of epidemics, the social crisis that develops, and the narrative that follows, tracing this sequence through different public health events. Americans worried excessively about an “anthrax” epidemic in the early 2000’s after several people died and became sick from opening letters contaminated with anthrax. Despite public fear, this was no epidemic, and the hysteria eventually died, but at a great public and political cost.
Contrast the fear of anthrax with the great epidemic of history- Plaque. In the 14th century, plague killed over 25 million people, one in four living in Europe. The moral narrative about plague imbued it with great social stigma, so much so, that in attempts to eradicate it, pogroms occurred against Jewish European communities, whose members were “blamed” for plague. Alcabes also traces the AIDS epidemic where gay men were heavily stigmatized as well as the links between cholera epidemics and political structures, such as those affecting Haiti and poverty.
A persistent theme underlying most of these narratives is that if someone is to blame for an epidemic, we will vilify them. Ultimately, the fear of “catching” a dreaded disease, whether it is tuberculosis, malaria, plague, HIV or cholera, can drive irrational decision making, rather than more straightforward public health approaches. This blame game obscure an approach of what we can and must do to prevent deaths. For instance, in Haiti after the recent earthquake, we could have prevented cholera transmission by providing safe sanitation.
Today, Alcabes believes that powerful interests, often times allied with politically profitable enterprises, have skin in the game about what gets defined as an epidemic. He challenges us to better understand that in a world filled with risks, deciding what is an imminent danger and what is not is critical. A fear of modernity as a cause of disease, from the internet and technology, to fast food or fast cars, should not cause us to panic, and we should not be “sold” future epidemics with the same fear that we approach truly known problems. Instead, we should admit that the major health problems facing society are systems problems, have multiple causes, and reflect usually competing priorities in nature or our social environment. One of the biggest problems for epidemic transmission today, Alcabes says, is fear and panic itself- thus the name of the book, DREAD.
In the end, Alcabes wants us, as physicians and patients, as consumers and policy-makers, to not only confront our anxiety over health in a world where longevity is increasing and where we can intervene quicker and more effectively than ever before in human history, but also deal effectively with the real epidemic diseases that still kill millions around the globe- like malaria, TB and diarrhea.
A minor criticisms of the book is that it fails to realize that today we are beginning to live in a world where chronic diseases kill more people than acute illness- and some of the chronic diseases are completely preventable, like cigarette smoking pushed and peddled by the tobacco industry. Another shortcoming is that the book blames many outside interests for creating fear, for making a narrative that provokes anxiety. This however, is not always true- for instance, the epidemic of impending dementia is something anyone fears who has witnessed their loved ones become unrecognizable.
We can all agree that if our goal is to save lives, we need to intervene now on the major causes of disease, with all effective tools at our disposal, whether it is AIDS or other contagion, nicotine addiction or global warming.
For this reminder to act, and not be paralyzed by fear or anxiety, DREAD is a wonderful read.