Health Affairs, 23, no. 2 (2004): 278-279 doi: 10.1377/hlthaff.23.2.278 © 2004 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Book Reviews

Resurgent History

The Return of the White Plague: Global Poverty and the "New" Tuberculosis
edited by Matthew Gandy and Alimuddin Zumla
(New York: Verso, 2003), 330 pp., $35

In the preface to this new edition of America’s Forgotten Pandemic: The Influenza of 1918, historian Alfred Crosby notes that his book, originally published in 1976, can no longer be dismissed as a work of medical antiquarianism. The global burden of AIDS; the threats of lyme disease, West Nile fever, and ebola; the resurgence of tuberculosis, especially in its menacing multi-drug-resistant form; and, most recently, the anxieties generated by the appearance of severe acute respiratory syndrome (SARS) have together "resuscitated the study of infection." So, too, studies of infectious diseases of the past, especially those of once terrifying epidemics and pandemics, can now command an audience of those eager to learn the lessons of history.

And what are those lessons? According to Crosby’s lively account, there are none that should give us much comfort in the present or confidence for the future. For back in 1918 medical and public health authorities were baffled by influenza, its associated pathological phenomena, and its microbiological and epidemiological patterns. No standard scientific or public health assumptions seemed to work, whether about causal mechanisms, preventive vaccines, environmental interventions, or behavioral prophylaxis. Instead, military and medical personnel stood by largely helpless as the disease first spread with explosive force in military encampments, then disastrously ping-ponged back and forth across several continents, between mobilized and transported troops, and between troops and surrounding civilian populations.

Everywhere the "Spanish Flu" spread, it sickened and killed in huge numbers, overwhelmed medical facilities, and slowed down or paralyzed military operations and domestic services. No locale ever seemed ready for the devastation of the disease, whose actual severity invariably exceeded even the most dire expectations (it is estimated to have killed thirty million people worldwide and some 550,000 in the United States), and in many places officials were unable to keep pace recording the number of cases or even burying the dead. Officials in many U.S. cities responded with confusion and ambivalence, ordering the closing of churches, schools, theaters, and places of public amusement while at the same time encouraging the maintenance of morale by staging mass displays of public patriotism. Pandemic and panic passed not because anyone learned lessons that proved useful but simply because, by March 1919, the disease had run its biological course.

Crosby makes much of biology and focuses on it as one of his central and recurrent concerns. He can, in fact, be chided for overvaluing biological considerations at the expense of social and environmental ones. Thus, he goes on at great length about how the disruptions and dislocations of war served to "maximize the exchange and propagation of different strains of flu viruses by people who were radically different immunologically" (p. 30); and he frequently hypothesizes the mutation of various flu strains, which led to a likely "mob of protean creatures effectively defended against vaccine by their diversity and mutability" (p. 290). He also includes lengthy discussions of the peculiar mechanisms of immune response in the pandemic’s young adult victims and traces the investigation of symbiosis theory, which posited that Spanish flu was a unique disease produced by two organisms, a virus and a bacterium, working together to create one lethal disease.

But Crosby is too cavalier about social and environmental considerations and dismisses most such ideas as speculations without merit, even when he feels compelled to record them. The possibility that the intensity of influenza in Europe owed something to food shortages or wartime emotional stresses is brushed aside, and the severity of flu among Native Americans and U.S. immigrants is countered by pointing to the relative hardiness of poor and underprivileged American blacks. Crosby even goes beyond his evidence to state that flu showed no "clear preference for the poor, the ill-fed, ill-housed, and shabbily clothed" (p. 227) and "ignored the differences between rural and urban, patrician and peasant, capitalist and proletarian, and struck them all down in similar proportions" (p. 323). But these exaggerated claims contradict some of his own data and ignore worldwide patterns, which show that the pandemic’s toll was far heavier in Sub- Saharan Africa and Asia than in Europe and North America. Crosby wriggles out of these difficulties time and again, regularly returns to biological speculation, and ultimately leaves his reader mystified by the elusive complexity of the disease.

No such mystification irritates the reader of Matthew Gandy and Alimuddin Zumla’s edited volume, The Return of the White Plague: Global Poverty and the "New" Tuberculosis. Although the work of some twenty-five authors, the thirteen chapters of this book cohere around a common and clearly stated theme: Tuberculosis and its latter-day history can only be truly understood in social, political, and economic terms. The authors share a vision that the editors neatly summarize in their Epilogue: "A shift of emphasis is required away from the TB bacillus as the ‘cause’ of the pandemic towards the social and political factors underlying the epidemiology of disease...In practice, of course, there are likely to be a combination of different strategies involved in any successful attempt to control the disease, but a reliance on biomedical innovations alone cannot hope to have any lasting impact" (p. 238).

Individual chapters illustrate and elaborate this theme, often brilliantly. In my reading, the most impressive, eye-opening, and sometimes breath-taking chapters are "Immigration, Race, and Geographies of Difference in the Tuberculosis Pandemic"; "War and Disease: Some Perspectives on the Spatial and Temporal Occurrence of Tuberculosis in Wartime"; "The Present Global Burden of Tuberculosis"; "Tuberculosis and HIV Infection in Sub-Saharan Africa"; "The Recent Tuberculosis Epidemic in New York City: Warning from the De-Developing World"; "Private Wealth and Public Squalor: The Resurgence of Tuberculosis in London"; and "The Social Impact of Multi-Drug-Resistant Tuberculosis: Haiti and Peru."

These titles merely suggest the richness of substance and subtlety of analysis to be found in this impressive volume. Suffice it to say that usually unexamined assumptions, victim-blaming stereotypes, and biological mystification are seriously challenged, as seemingly resurgent and multi-drug-resistant tuberculosis is placed fully in its social, economic, political, and historical contexts. There is still hope that we may be able to learn the lessons of history and apply them with good results in the future. As far as infectious disease is concerned, The Return of the White Plague will serve as a far better guide than America’s Forgotten Pandemic.

Theodore M. Brown

Editor's Notes

Theodore Brown is professor and chair of the Department of History and professor of community and preventive medicine at the University of Rochester (New York). He is a contributing editor (History) of the American Journal of Public Health and is senior adviser to the Global Health History Working Group of the Rockefeller Foundation’s Joint Learning Initiative: Human Resources for Health and Development.

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