Category: Medicine

Spillover

Cover image for Spillover by David Quammenby David Quammen

ISBN 978-0-393-23922-5

“Make no mistake, they are connected, these disease outbreaks coming one after another. And they are not simply happening to us: they represent the unintended results of things we are doing.”

I picked up this book because my last couple of pandemic reads had left me particularly curious about the phenomenon of zoonosis. Zoonoses are diseases that originate in animals, usually harboured by a reservoir—a species that chronically carries the bacteria or virus but is not sickened by it—and are transmissible to humans. When the right set of circumstances occur, when the fragile ecological balance of the world is disrupted in a new way, a pathogen can spill over from animals to humans. Sometimes, that spillover is a dead end; the circumstances are so unique that they may never occur again. Or the virus can be transmitted to humans, but not between people: game over. But the thing that keeps virologists up at night is the pathogen spillovers that are not only virulent—highly deadly to humans—but also highly transmissible between humans once the species boundary has been breached. With the possibility of the Next Big One always looming, David Quammen takes the reader through famous outbreaks of zoonotic illnesses, with sections on Hendra, Ebola, malaria, SARS, Lyme, Nipah and HIV.

David Quammen is a journalist with a long history of covering zoonosis, with the consequent experience in translating a highly technical subject for a lay audience. As detailed in the book, his field journalism has taken him on several expeditions with top scientists working to trace the origins of various zoonoses, from Africa to Asia, following bats, gorillas, and chimpanzees. He interviews people as world famous as Jane Goodall, and specialists who are only rockstars to those who pay close attention to the world of virology. Spillover was published in 2013, and presages not only the 2014 Ebola outbreak, but the current COVID-19 situation as well. That isn’t to say that Quammen or his experts explicitly predicted it; in fact, the final chapter of the book focuses on influenza in particular, and the possibility of avian influenza (H5N1) achieving human-to-human transmission. But COVID-19 is, like influenza, an RNA virus with all the rapid mutation that entails. The broad point is not predicting any specific spillover, which would be virtually impossible, but rather illuminating the circumstances that make these types of events all but inevitable.

One very interesting trend that emerges is bats, which have been implicated as the reservoir host for a variety of spillover viruses. Nipah and Hendra, for example, are confirmed to originate with bats. In his 2006 book China Syndrome, Karl Taro Greenfeld followed the trail of SARS to palm civets in southeastern China’s wild animal markets. But in Spillover, Quammen takes the reader through more recent evidence that palm civets were actually an amplifier or transitional host that enabled the virus to reach humans from bats. Although the reservoir for Ebola remains unconfirmed, virologists are looking at bats with great interest. Unfortunately, Quammen’s reporting reveals that the significance of bats in all this is still poorly understood. It could just be that there are so many bats; at 1116 species, they account for one quarter of all mammal varieties. The fact that they live in large roosts conducive to spreading the virus within their communities, combined with their mobility and range could also be significant. But until bat immunology is better understood, the answer to why so many spillover events seem to originate with bats cannot be more than speculative.

I also found the section on HIV/AIDS particularly interesting because most of the books I have read on the subject focus on the cultural history, specifically the impact on the gay community. None of those books have tended to look further back than the Canadian flight attendant who become known as Patient Zero in a study that focused on a North American outbreak cluster in the early 1980s. Quammen’s interest is more epidemiological, and the story of HIV is particularly fascinating because the science suggests that the spillover event took place much earlier than one might have expected—perhaps as early as 1908. However, this section does get a bit bogged down with a long, imaginative tangent where Quammen uses the little available evidence to extrapolate a narrative sequence about a hunter who ultimately brings HIV out of the forest. The true Patient Zero for HIV will never be known, and while Quammen’s imagining isn’t implausible based on the available evidence, it nevertheless feels out of place in this otherwise very factual book.

Spillover is on the long side—the print edition comes in at nearly 600 pages—and a bit technical at times, but if you’re only going to read one book about epidemics, this one combines multiple outbreaks into a single volume, highlights trends and commonalties, and provides a good basic understanding of  the relationship between virology, ecology, and epidemiology. The chapter on Lyme disease is particularly apt in its illustration of how important the ecosystem is to prevalence of a disease. If you’re not up for the full volume, Quammen has published Ebola and The Chimp and the River, both short extracts from this larger book focusing on Ebola and HIV respectively. If, like me, information is your coping mechanism of choice at the moment, you’ll emerge from Spillover with a much better contextual understanding of our current situation, armed with many of the essential concepts for understanding the virology and epidemiology underpinning the ongoing public health conversation that will be dominating our discourse for the foreseeable future.

You might also like Pale Rider by Laura Spinney

China Syndrome

Cover image for China Syndrome by Karl Taro Greenfeld by Karl Taro Greenfeld

ISBN 978-0-06-185153-7

“The season of SARS could be viewed as either an anachronism or a harbinger.”

Over the winter, a new virus emerged, sickening its victims with a severe respiratory illness that manifested with a high fever and a hacking cough. For an unlucky few, the illness degenerated into total respiratory failure as the lungs filled with fluid, and the organs shut down from lack of oxygen. As Lunar New Year approached, the Chinese government continued to insist that the situation was under control, even as cases began to spread. The story is eerily familiar, because we have all been living it. But Karl Taro Greenfeld’s 2006 book China Syndrome is a chronicle not of COVID-19, but of the SARS epidemic caused by a similar novel coronavirus that jumped the species barrier and sickened thousands in 2003 to 2004. At the time, Greenfeld was the managing editor of Time Asia, and based in Hong Kong, the first place outside of mainland China to be affected by the epidemic. The big news story of the year was expected to be the American invasion of Iraq. Instead, Greenfeld and his staff found themselves on the frontlines of reporting on the twenty-first century’s first major epidemic.

Each chapter is headed with the location and date, as well as the number of people estimated to have been infected or dead of SARS. The death rate in these estimates hovers around a chilling ten percent, and also grows in increasing contrast to the Chinese government’s public refusal to adjust their official numbers upward even as people continued to sicken and die. The book is insightful about the cultural conditions that lead to the denial and cover up. Greenfeld highlights the unprecedented transition of power that was occurring in Beijing at the time, as well as the emphasis on saving face and avoiding blame. Particularly telling is the fact that information about a disease outbreak is classified as a state secret in China. It was illegal to disclose this information anywhere but up the reporting line. Greenfeld witnessed a doctor arrested for talking to him about the outbreak, and another doctor that spoke up spent the rest of his life under house arrest. A Hong Kong virologist risked arrest by traveling across the border repeatedly to smuggle samples for his lab, since it was impossible to get any information out of the Chinese Ministry of Health.

Coming in at seventy-three—albeit often short—chapters, China Syndrome does feels somewhat drawn out, especially in the early chapters before the agent of the disease has been identified. As Greenfeld points out, however, the specific agent often isn’t all that important if doctors can treat the disease with existing methods. Investigators were at first highly focused on the possibility of avian influenza, and it is almost halfway through the book before the term “coronavirus” is even mentioned. By comparison, however, it took more than two years for scientists to isolate the agent responsible for the AIDS epidemic. The race for the answer features internal and international rivalries, and more than one false step along the way.

Before you decide to pick this one up, I would issue a warning for a few more graphic parts of the book. It includes descriptions of the conditions market animals live in, and how they are restrained and killed on site at the restaurants that serve them. Greenfeld also describes the liquidation of livestock that occurred once the virus’ host animal was identified and banned from sale. In the medical section, there is a detailed description of intubation that serves to illustrate why the procedure posed such a risk of infection to the healthcare workers who performed it on SARS patients. These don’t form huge swathes of the book, but it is worth knowing they are in there.

There is a definite sense of eerie deja vu in reading this book, from the slowly escalating rumours, and mutters about biological warfare, to the runs on particular kinds of equipment and supplies, to the very timeline and symptoms of the illness itself. Yet perhaps the most eerie part is the unheeded warning that SARS now represents. As Greenfeld details, the Chinese government banned the sale of the animal found to be the reservoir of the virus, and seized and destroyed the existing stock. But the closure of the urban markets where live animals were sold was only temporary, and within months they were back in business, operating much the same as before, with thousands of diverse, defecating, bleeding, doomed animals trapped in close quarters with one another, and the people who sold, butchered, and consumed them. One threat was eliminated, but the conditions for another such zoonotic outbreak remained much as they ever were.

You might also like Pale Rider by Laura Spinney

Pale Rider

Cover image for Pale Rider by Laura Spinneyby Laura Spinney

ISBN 978-1-61039-768-1

“The number of dead could have been as high as 100 million—a number so big and so round it seems to glide past any notion of human suffering without even snagging on it. It’s not possible to imagine the misery contained within that train of zeroes. All we can do is compare it to other trains of zeroes—notably the death tolls of the First and Second World Wars—and by reducing the problem to one of maths, conclude that it might have been the greatest demographic disaster of the twentieth century, possibly of any century.”

The influenza epidemic that began in 1918—which became known as the Spanish Flu—has drawn a lot of interest in recent months as comparisons are made to the current situation with COVID-19. Pale Rider by Laura Spinney was published in 2017, shortly ahead of the flu pandemic’s centenary year. As such, it is quite current, but of course does not directly address our present circumstances. Spinney tracks the influenza’s two year path around the globe, while also providing historical context, history of medicine, and a significant look at recovery and collective memory as it relates to the pandemic. By the numbers, the contemporary estimate of deaths was 20 million, but over the years that has risen to 50-100 million as more records and evidence come to light. Probably about one in three of the then 1.8 billion living people would have become infected, and while most recovered, up to five percent of the sick may have perished.

I selected this title from among a few popular books about the 1918 pandemic as it is noted for its attempt to take a more global approach to understanding the outbreak. Other previous titles have a more North American and European focus, despite the fact that these areas were not the hardest hit. According to Spinney, that dubious honour likely goes to India, though the numbers for China are murky. In addition to addressing the first recorded case, at Camp Funston military base in Kansas, and covering the impact on the Western Front as well as the acquisition of the “Spanish Flu” nomenclature, Spinney goes further afield to dig into the available numbers for places as various as China, Persia, India, Australia, Iceland, and more, resulting in a more complete picture of the global impact.

The structure of the book is circular, and somewhat repetitive. Rather than following a chronological timeline, Spinney takes a locale-by-locale approach that covers the same chronology multiple times in different places. Despite the repetition, this is an effective structure for sinking into each location and getting a full sense of their experience of the pandemic, which had huge regional variations. Australia, for example, experience only the third wave, having effectively kept out the deadly second wave with a maritime blockade. Spinney also covers three major theories about where the flu may have emerged before it surfaced and was recorded in Kansas, but with a careful eye to the contemporary prejudices that may have been shaping these hypotheses, particularly with regard to China. Within the United States, she addresses the tenements of New York, as well as the remote villages of Alaska, and highlights how differences in responses between cities led to vastly different death rates.

In addition to tracking the pandemic, Pale Rider provides and explains historical context about where the development of medical understanding and technology stood when the pandemic began. Notably, the electron microscope was not invented until the 1930s, meaning that while bacteria could be seen on an optical microscope, viruses—which are about twenty times smaller—were still invisible. Spinney briefly traces the evolution of Western medicine in relation to contagious diseases, and in specific locales such as Indian, China, and Persia, she also addresses how this knowledge was interacting with local medical traditions like Ayurveda. In the West, she also briefly chronicles the backlash against traditional doctors for their failure to prevent the outbreak in the first place.

A notable cautionary note that emerges from Pale Rider is the danger of mass gatherings for any purpose. Influenza does not distinguish between a church service and an armistice parade, a wedding or a funeral. Particularly chilling is Spinney’s account of the Spanish city of Zamora, which was among the hardest hit in that country. Zamoran congregations actually swelled as the pandemic raged, and the populace sought solace and prayed for relief. The city had a zealous new bishop who encouraged religious gatherings, called novenas, promoted the adoration of relics, and continued to distribute communion, all activities that send a shiver down the spine of anyone with a current understanding of the germ theory of disease.

In the latter part of the book, Spinney dives into the difficulty of trying to tease apart the inextricable impacts of the one-two punch that was the Great War with a pandemic following close on its heels. Although more people died in the pandemic, the war remains much better remembered, though Spinney suggests that the centenary is changing that, and no doubt the current situation will also contribute to the revival of interest. For those wondering whether they would be up to reading this book at the moment, I found the author’s approach thorough, but largely not grisly, though there are some dark spots. Spinney leans more towards statistics rather than graphic descriptions of the physical suffering of the flu victims.

Being Mortal

Cover image for Being Mortal by Atul Gawandeby Atul Gawande

ISBN 978-0-8050-9515-9

“Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.”

In 1945, most Americans died at home. By the 1980s that number was down to 17%. Today it is trending back upwards as more people pursue options that allow them to live out their final days in the comfort of their own homes. Doctor and writer Atul Gawande explores how dying became medicalized in the intervening years, as science offered new innovations for beating back disease in the 20th century. Encompassing both the elderly and the terminally ill, Gawande examines how end of life care falls short of providing patients with the best possible quality of life in their final days, instead focusing on what else can be tried to fix the unfixable, and beat back the inevitable. From nursing homes to cancer wards to assisted living facilities to hospice care, Gawande reveals the shortcomings of the institutions we have created for the dying, and asks how we can be better prepared to face the question of mortality with clear eyes and compassion.

Atul Gawande’s previous books Better and The Checklist Manifesto both make it amply clear that he takes continuous professional improvement extremely seriously. In Being Mortal, he examines how society and the medical system can improve the treatment and care of elderly and terminally ill patients. Using the case of his wife’s grandmother, he shows how North American nursing homes commonly fall short, by focusing on safety rather than quality of life. Turning to his own grandfather in India, he shows some of the comparative advantages of multi-generational in-home care, but also highlights the inter-generational conflicts and tensions that can arise from this living situation. In the end, he concludes that both models fall short of providing the elderly with the level of control they need to have over their lives in order to be happy.

Gawande is wary of over-idealizing care provided by children in their homes for their elderly parents. In addition to his own grandfather, he uses the case of Shelley and her father Lou to show the stresses and tensions that this can result in. However, many people feel that this model is the ideal, and it is commonly argued that the decline of children caring for their parents indicates a lack of respect for elders in North American culture that comes from the veneration of youth. But Gawande has a slightly different take. He argues that what is being venerated is not youth, but the independent self, and both nursing homes and living with one’s children degrade that independence which is so central to the North American identity. But this way of thinking offers up a question that has been insufficiently answered: “if independence is what we live for, what do we do when it can no longer be sustained?”

Gawande talks about patients, both his own and those he meets in the course of his research, talking with geratiatricians and hospice care workers. He also draws on examples from his own life. Early in the book, he discusses the situation of his wife’s grandmother, Alice Hobson, who lived independently for many years, but eventually began having falls that made it too dangerous for her to continue living alone. She ultimately ending up in a nursing home she despised. Later, after he has explored the nuances of geriatric and hospice care, Gawande approaches the case of his own father, who was discovered to have a slow-growing tumour in his spine when he was in his seventies. His father’s case shows Gawande putting his new skills to use, but equally demonstrates that life is complicated and unpredictable, and that even with this knowledge, the end of life will not necessarily be ideal. Gawande is offering hope and help, not a magical solution that will make every difficult situation easy.

Being Mortal is a book that is important for young and old alike. For those facing choices about where and how they will live in their last years, Gawande offers food for thought about the different options available. Younger readers will be better prepared to navigate these conversations with their parents. And of course, anyone of any age can find themselves faced with an unexpected illness that catapults them into facing their own mortality sooner than they might have wished or planned. Readers will emerge with a better understanding of the warning signs of decline that can severely limit independence, the factors that most affect satisfaction with elder and hospice care for the patients, and questions to use in discussions with doctors and loved ones.

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You might also like When Breath Becomes Air by Paul Kalanithi

Black Man in a White Coat

Cover image for Black Man in a White Coat by Damon Tweedyby Damon Tweedy

ISBN 978-1-250-10504-2

“When I started medical school and learned about the adverse health outcomes that afflicted black people, I had assumed these disparities were chiefly due to genetics. To be sure, there are diseases like sickle-cell anemia, lupus, and sarcoidosis, which appear to preferentially target black patients at a biological level. But what had become abundantly clear to me during my years in medical school and as a doctor, however, were the many ways that social and economic factors influence health, and, more than anything else, account for the sickness and suffering that I have seen.”

The son of a working class African-American family from Maryland, in 1996 Damon Tweedy accepted a scholarship to Duke University Medical School. As he began learning about various diseases and conditions, he was soon bombarded by a familiar refrain: “more common in blacks than in whites.” Tweedy initially assumed these problems were genetic vulnerabilities, but his experiences soon led him to realize that social and economic factors were, in most cases, much more significant, and in turn these factors play out “along racial lines.” Initially intent on avoiding drawing any attention to his race, Tweedy instead becomes interested in reducing these disparities.

Tweedy divides his books into three parts, proceeding chronologically, first from his medical training at Duke, onto his internship, and then into his practice as a psychiatrist. Each stage presents new challenges. As a student, one of his professors mistakes him for a maintenance worker come to change the lights in the lecture hall, then tries to pretend that the error never occurred. In medical school, Tweedy must balance the well-being of his black patients against the problems that might be caused if he confronts his superiors. He is relieved, in one case, when the supervising doctor is the one to challenge a white nurse who asserts that a nineteen-year-old black woman who suffered a placental abruption after smoking crack cocaine should be sterilized. Later, in his own practice, he confronts new challenges, such as treating a biracial woman who is afraid of black men because of how her black father treated her white mother.

As a scholarship student, Tweedy starts out with an inferiority complex, afraid that people will think he does not deserve to be in medical school. He fears anything that will draw attention to his race, and cringes at every mention of racial medical statistics. This initial fear tempers somewhat, but it leads to his very cautious and measured approach in this book. Tweedy largely skirts around more controversial topics such as the war on drugs and discriminatory policing, both factors which contribute to the shortening of black lives.

Through a more personal lens, Tweedy also examines his own health problems. He discovered his high blood pressure when he and a classmate were practicing taking vital signs in their first year of medical school. A follow-up visit to the doctor also revealed early signs of kidney failure, prompting Tweedy to rethink his diet and exercise routines. This helps him relate very personally to the difficulty patients have making lifestyle changes for the sake of their health. But while he realizes that his own blood pressure and blood sugar are more important health metrics than his weight, since he remains naturally thin throughout, he doesn’t seem to extend this insight to patients, often remarking on their weight. He also fails to stand up for a black patient who wants to try lifestyle changes before going on blood pressure medication, afraid that he will be considered a racial agitator if he challenges the other doctors.

This book felt particularly relevant at the time of reading, as news went viral of a Delta flight attendant refusing to believe that Tamika Cross, a Texas obstetrician and gynecologist, was a doctor. Tweedy’s experience makes it abundantly clear that there are disparities for black doctors and patients alike, and that they play out in subtle ways throughout the medical system, but add up to a large gap in care. What is less clear is the path forward. The Affordable Care Act is acknowledged as something that may help some patients, but not enough. Nor does Tweedy feel that every black patient needs a black doctor; he more than once trips over his own assumptions about black patients, and encounters skepticism of his credentials among both black and white patients. But his stories provide a window for issues that deserve broader consideration.

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Cover image for When Breath Becomes Air by Paul KalanithiYou might also like When Breath Becomes Air by Paul Kalanithi

When Breath Becomes Air

Cover image for When Breath Becomes Air by Paul Kalanithiby Paul Kalanithi

ISBN 978-1-4104-8785-8

“I was less driven by achievement than by trying to understand, in earnest: what makes human life meaningful? I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain.”

After ten years of medical education, Paul Kalanithi was on the verge of completing his training as a neurosurgeon when he became concerned about his own health. At first he blamed the rigours of residency, but a CT scan soon revealed the worst: cancer in the lungs, spine, and liver. Early in his university career, Kalanithi studied literature, dreaming of a career as a writer, but was driven to medicine by questions about mortality and meaning that he felt could not be answered by literature alone. Suddenly, those questions became urgent and personal, and the only time left to write a book and achieve that dream was now.

Kalanithi’s February 2014 New York Times op-ed “How Long Have I Got Left?” was a viral sensation. Two years later, Kalanithi is dead, but his book, When Breath Becomes Air, has been on the New York Times best-seller list for twenty-nine weeks as of this writing. It sits a few spots above Being Mortal, by fellow Indian-American doctor Atul Gawande, which has been on the list for eighty-one weeks. Clearly the theme of mortality has struck a nerve.

When Breath Becomes Air is both short (280 pages) and fast-paced. One moment Kalanithi and his wife are considering whether or not to get pregnant, and a couple pages later, she is three months along. At no point does he arrive at the moment he decided to start writing the book, though his connection to literature is evident and explored. The style, the sense of rushing, is literally characteristic of the state in which Kalanithi was living; the timeline he had expected suddenly sped up and warped beyond recognition. When Breath Becomes Air is, in a sense, unfinished, derailed by Kalanithi’s rapid decline. But that is an essential component of its truth, of the reality that he faced.

Up front, Kalanithi admits that he and his wife were struggling at the time of his diagnosis. The long hours of medical school and residency—his wife is also a doctor—had taken a toll on their connection. But I was moved by the fact that his illness reconnected them. I didn’t get the sense that Lucy stayed out of obligation, but rather that the diagnosis stripped away everything that had gotten between them over the years. To be honest, Lucy Kalanithi’s epilogue was the part of the book that affected me most. This is, perhaps, unfair. She had time; time to reflect, and time to polish, a luxury her husband did not enjoy.

Kalanithi’s concern with seeking the meaning of life is largely philosophical, and occasionally religious. He is able to approach his death theoretically and intellectually, in a manner that can almost seem cold, even as it is also obviously the fire that drove him into medicine in the first place. After getting two degrees in literature, Kalanithi put off his dream of being a writer to pursue the medical side of this question, imagining a literary career could wait until after he was an established neurosurgeon and researcher. He is idealistic, and even romantic, still finding his voice even as he loses it. When Breath Becomes Air is simultaneously reflective and rushed, because while Kalanithi is concerned with big, deep questions, he was left with little time to ponder them.

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Further reflections on life and death: Mortality by Christopher Hitchens