A pandemic pathogen is scary and strange. It is new to medical science and society and it is everywhere. At the critical early moment of a pandemic, much of the advice of doctors and epidemiologists will be vague and some will be wrong. Those who know their subject best will have the deepest uncertainties. No expert can say when and how the pandemic will end. There isn’t even an agreed definition of ‘pandemic’ – an arcane but revealing absence.

Public leaders pay homage to ‘following the science’ but they actually follow a script. It’s a storyline with a reassuring ending. It goes something like this:

We are at war against an invisible enemy. While our doctors and nurses combat the disease at the frontline in hospitals, while our scientists seek the cures and vaccines in their laboratories, the population must make sacrifices on the home front. We should trust our government while we forgo liberties and livelihoods. The pandemic will end with a medical magic bullet that vanquishes the pathogen. Then we will return to our way of life and be safe.

This is the basic outline of a war story. It’s also a tale of conquest of the microbial world and a charter for emergency rule that sets aside human rights and civil liberties. ‘War on disease’ is not a harmless metaphor. It suppresses critical thinking. It focuses our worries on a singular germ as our enemy, forgetting about other things – such as devastated ecologies and an inequitable society – that are no less pathogenic. And its comforting ending is false – even if the discovery of a vaccine or therapy means that leaders feel entitled to declare ‘victory’.

This book is about this gargantuan and harmful error. It is about how and why the ‘war on disease’ script was written and how it guides our thinking and shapes our institutions in ways that we may not realize. When we most need a narrative to make sense of a devastating pandemic, the ‘war on disease’ not only fails, but also stops us recognizing our failures. This book is also about some very different visions. Scientists, social activists, and public health experts have other analyses and narratives – rigorous, practical, democratic, holistic – that we should pursue. The Covid-19 pandemic and crisis is showing us that the ‘war on disease’ is at best humdrum and at worst dangerous, and that these alternatives are urgent.

The ‘war on disease’ script is like the sheaf of documents in a desk drawer seldom opened. It consists of a handful of different scripts, pictures, and reminders. Some are Chinese, most are European or American. Also in the drawer are other images for disease outbreaks: a journey, an imbalance in the cosmos, a crime investigation, a storm, and a forest fire.¹

In an emergency, we think fast and intuitively. To change the metaphor, being caught by a pandemic is like being caught in a storm when hiking in the mountains: suddenly the clouds roll in, darkness descends, rain lashes down, and the stones become slippery. We can’t stay where we are, and we can’t wait for the storm to clear to look around and find the best way down – we want to find a way to safety right away. There’s a handrail: we grasp onto it because it keeps us steady. This handrail is our intuition, built from metaphors, storylines, images, and memories of what worked in the past. It’s more than just a thesaurus, it’s actually how we think – and so it usually goes unexamined. In the moment of greatest turmoil, fear, and uncertainty, it’s reassuring. The handrail makes each step feel safe, and we assure ourselves that we can look at the map later on. That map will show us some other directions we might have taken, had we stopped to orient ourselves more carefully. We may regret that we didn’t pause for a few moments to consider those other paths.

Experts on pandemics like the storm metaphor. The influential health scientist Michael Osterholm has compared an influenza pandemic to a blizzard and coronavirus to a hurricane.² In 2007, the United States Federal Government published a preparedness plan that adapted the five-level tropical storm classification scale for use in responding to epidemics (where a ‘category 5’ is the most destructive).³ It grades national-level disease outbreaks in terms of fatalities. According to its rankings, Covid-19 in 2020 would be category 2 (that is, an order of magnitude less severe than some of the diseases anticipated.) The scale may be a useful prop for getting politicians to take notice, but it reproduces an elementary mistake. A pandemic isn’t just a disease outbreak or epidemic multiplied to pan-continental size. Scale is important, for sure, but there’s a qualitative aspect as well. The World Health Organization (WHO) stirred controversy in 2009 when it quietly changed its definition of an influenza pandemic. The previous definition was ‘when a new influenza virus appears against which the human population has no immunity, resulting in several simultaneous epidemics worldwide with enormous numbers of deaths and illness’. The revised one cut out the words ‘enormous numbers of deaths and illness’.⁴ A pandemic that doesn’t cause massive human suffering might seem odd to the layperson, but the virologists’ particular concern is the newness of the pathogen and not how many people it sickens and kills. The novel coronavirus that causes Covid-19 is exactly such a candidate. Its closest relative is severe acute respiratory syndrome (SARS), which emerged in 2002, and it has some epidemiological similarities to influenza, but Covid-19 possesses characteristics all of its own.

For doctors, microbiologists, and epidemiologists, what matters in the storm isn’t so much the wind but the darkness: we can’t see our way. There’s a trope among crisis epidemiologists: if you’ve seen one pandemic, you’ve seen just one pandemic.⁵ The health metrics expert Chris Murray described constructing his model for Covid-19 as ‘forecasting the weather while trying to build the forecasting tools’.⁶ Perhaps we should adapt the storm metaphor to capture the fact that each pandemic isn’t just a hurricane, it’s a new kind of weather condition. Margaret Chan, Director General of the WHO in 2009, observed ‘the virus writes the rules’.⁷ Those rules govern how the disease is transmitted, which people are symptomatic and which are contagious and when, and what the microbe does to the human body and brain. It can take years to figure them out. In the case of the novel coronavirus, science has moved with unprecedented speed, but it is still lagging behind the epidemic curve. What we do during that lag is what’s most important.

We like to think that biomedical scientists can provide authoritative certainty. As a pandemic hits, that isn’t so. They are confident that their research methods will provide answers, but they don’t have them yet. A new pathogen is an off-model event and models don’t (by definition) predict them. In these events, it’s the narrative that counts.⁸ Scientists also have difficulty in explaining what their uncertainties mean to the public. In turn, every doubt or debate feeds the appetite of denialists, conspiracists, and pseudo-scientists, such as anti-vaxxers. In America, changes in advice to the public from the Centers for Disease Control and Prevention (CDC) in the early days of Covid-19 – initially advising against stopping incoming travellers from Europe and China⁹ – have been repeatedly brought up by far-right pundits purportedly to show that public health authorities can’t be trusted. Public health spokespeople and science journalists find that debating denialists registers somewhere between irritation and enraged despair. The difficulty is that the history of medicine includes enough moral outrages, good-faith errors, and unanticipated calamities to justify critical questioning. But leveraging these concerns to assail the whole edifice is to misunderstand the nature of scientific authority. To the religious dogmatist, authority is flat: all statements of scripture possess the same sacred quality, and to doubt one is to doubt all. To the scientific mind, theories are open to revision, technologies are not infallible, but facts are real.

Science is itself a journey. Every time the climbers reach a summit, they see a new vista of peaks and valleys to explore. The history of science shows that understanding a pandemic pathogen isn’t merely an increment to existing medical knowledge but can also be a paradigm-shifting breakthrough. For each of the main pathogens examined in this book – cholera, influenza, and HIV, plus yellow fever and Ebola, which are covered more briefly – the search for prevention and cure has taken scientists into new terrain they could not have anticipated. Of all the sciences, medicine is the one most focused on the human being as such, and it is notable that it has been biologists who have blurred the boundaries of the human self, imputed agency to microbes, and in other ways challenged the distinction between the natural world and the human, so foundational to our modernist worldviews. Bruno Latour has made the same observation with regard to those hardest of hard scientists, geologists, who coined the word ‘Anthropocene’ to refer to our current era in which human activities are determining the global ecosystem. He writes: ‘No postmodern philosopher, no anthropologist, no liberal theologian, no political thinker would have dared measure the influence of humans on the same scale as rivers, volcanos, erosion and biochemistry.’¹⁰ In medicine as in geology, such critique doesn’t come from post-modernist literary theorists, but from the Sherpas of scientific exploration themselves. We will see that this is the case for Covid-19 too.

Pandemics move faster than politics. In the early acute phase, the number of cases of a disease can double every few days. It’s a frightening trajectory. A week is a long time for a pathogen, as it is in politics.

Public leaders must act very quickly. Individuals who hold high office are, in general, attuned to their constituents’ anxieties and what those may mean for the political order and their own political standing. They’re not usually very literate in the science of infectious diseases and they don’t have time to learn anything new and complicated. At that moment of darkness and uncertainty as the pandemic storm breaks, ministers and presidents want reassurance – for themselves and so they can provide leadership in the hour of crisis. Their task is to control the narrative, to buy time and calm, so that public health and medicine can control the disease.

A government leader has scientific advisers. For medical issues, that means biomedical scientists. The hierarchy of academic disciplines becomes desperately important at this moment of crisis because this is the order in which the decision-maker consults them, and the weight that their advice carries. This is shown by Nancy Krieger, who compares the number of projects funded by the US National Institutes of Health for the hard biomedical sciences as against social epidemiology: the ratio is 25 to one. Peer-reviewed publications favour the hard biomedical sciences 194 to one.¹¹ Between the academic top table and the rest of the scholarly hall there’s a huge step down – more of a precipice than a gradient. Next in the ranking are the epidemiological modellers, below them the social epidemiologists, and last the medical anthropologists and historians. Ecological scientists sit somewhere in the middle. This hierarchy corresponds roughly to the ‘hardness’ of the science, and depending on where a researcher sits, everyone above him or her is a true ‘hard scientist’ and everyone below a ‘soft’ one. It’s a gendered hierarchy – there are far fewer women in the higher reaches. Those at the farthest end of the hall – who study literature, history, and social anthropology – like to critique and deconstruct the hierarchy and mock the pretensions of those at the top. Meanwhile, hard scientists tend to go softheaded when they cross the boundary into social and political analysis – they turn to platitude and metaphor. They know what ought to be done: it’s just a matter for the public, or society, or whoever, to get on and do it.

Most scientists’ approach to public messaging has been that facts speak for themselves. This hasn’t worked. Towards the end of his book Spillover, the journalist David Quammen inadvertently shows how scientific thinking loses its compass as it crosses this divide. In 500 pages, he vividly describes the work of virologists who hunt down and analyse pathogens that have either made the zoonotic jump from animals to humans or have a fearsome potential do so. It’s fascinating. These scientists are, he says, ‘our sentries’ who will ‘raise the alarm’. Quammen continues: ‘What happens after that will depend upon science, politics, and social mores, public opinion, public will, and other forms of human behavior. It depends on how we citizens respond.’ Those ways of responding are ‘either calmly or hysterically, either intelligently or doltishly’.¹² This is true but it also doesn’t get us far: social scientists and political analysts have useful things to say on these topics. They too have their hierarchy, with economists at the top table. But a pandemic is a rare occasion in which economists don’t have a model to hand,¹³ though they have much to say about what can be done to mitigate the crises of paying for health care, unemployment, and disruption to international trade. Macroeconomic models that take equilibrium as a premise don’t work when – as in a pandemic – there is by definition no equilibrium.

Politicians talk to their friends and financiers in business, who are also used to making complex decisions quickly in uncertain situations. Business school methods that focus on real-world problems can be useful when the data are speculative and the quantitative formulae have just been thrown out of the window. The core business management question is ‘what is going on here?’ and the answer is given by means of a story that makes sense. So far so good. That works when our intuitions have been refined by experiences that fit the problem. But it doesn’t work when the problem follows a new logic for which our thinking need to be rewired – for example a novel pathogen.

The security advisers have a narrative too. Their job includes planning for a full spectrum of hazards, including all manner of nasty surprises. Military officers and intelligence analysts have played out wargames with both humans and natural disasters as the enemy ‘red team’ and have watched how decision-makers respond to the stresses of the unexpected. One of those exercises, repeated every year or so in governments of industrialized countries, is the crisis of a highly contagious germ introduced either by a terrorist with access to a high-security biotech laboratory, or by natural spillover. So the security analysts consider themselves ready – or at least a step ahead of others. But they can’t anticipate what rules a new virus might follow. They also suffer the handicap of those tasked with imagining the unanticipated, which is that in order to make their story credible – plausible enough to convince a jaded politician – they can only break one or two rules about normality at a time. In the same way that a science fiction movie stretches our imagination on one dimension but sticks to a conventional plotline and characterization so as not to bewilder the audience, so too the pandemic disaster scenario hews to an intuitively resonant human script. These rules are written by the scriptwriter. This is why, almost inevitably, the reality of a pandemic will be stranger than fiction or a security studies wargame simulation. This naturally won’t become clear until later. In emergency mode – and most politicians have an adrenaline rush when there is a real emergency, with top-secret briefings with the highest-ranking generals and spy chiefs – those security-based narratives, scary but familiar, will resonate.

Routinely, a political leader will talk to other politicians. The normal calculus of day-to-day politicking about loyalty, jobs, money, and the media doesn’t stop. We hope that in a national emergency, all those become secondary to the public good. One of the virtues of a pandemic-as-national-security drama is that it allows a leader to rise above party politics and set a truly national agenda, even a global one. Every politician also knows that they should never let a crisis go to waste. For some, the chance for partisan gain trumps the public good. There are benefits to pandemics: an opportunity to seize emergency powers and use them to other ends, spend public money with little oversight, and get on with other factional business while public attention is distracted. Some leaders are denialists. A few are devout denialists, who genuinely think the disease is a hoax or truly have faith that religious piety is sufficient to prevail. Others are tactical denialists, for whom challenging the science or letting turmoil spread brings immediate political advantages. More common are those who pay enough attention to half-convince themselves of a simplified storyline, and then screen out contradictory information.

In a crisis, political leaders don’t usually consult the people, because it’s complicated and takes time and they don’t know what questions to pose. For those who are genuinely committed to democracy, or to finding the best all-of-society way through the crisis, it’s a short-cut that they will come to regret. But the mistake is easily made because there’s no readily available template for a democratic pandemic response.

It should be clear by now that science cannot provide certainty for political decisions in the moment of a fast-moving pandemic. The ‘war on disease’ storyline steps in for that purpose. The reason why government leaders find it useful is because it’s reassuring. Unfortunately its reassurances are false. To call on a new metaphor, the warfighting script is like those well-worn, half-forgotten clothes at the back of the wardrobe that are pulled out for an unexpected occasion. They don’t really fit but there’s nothing else to wear on the day. And besides, they are at least inconspicuous because everyone else is wearing something similar. Hence the title of this book: the pathogen is novel and unpredictable, the political scripts are familiar and predictable from the first word to the last.

We shouldn’t take the martial language too literally, and those who know it are well aware that it’s not a ‘real’ war. Scientists and public health experts see it as a way of validating their work, as an innocent cover story that appeals to a spirit of solidarity and selflessness and helps us cope with dangers and setbacks. Those are fair considerations, but the script has other consequences too. Policies are standardized and imposed by decree. The archetype is how the German imperial government defeated cholera in Hamburg, described at the end of chapter 2, and the American army’s conquest of yellow fever in Cuba, Panama, and the southern United States, described at the beginning of chapter 3. The way in which HIV and AIDS policies became part of an international security regime is examined in chapter 4, and in chapter 5 I will show some of the errors made by militarizing the response to Ebola. In America, the role of soldiers in ‘fighting’ diseases helps validate the apparently limitless expansion of the tasks given to the Pentagon – a definitional inflation that makes ‘war’ at once all-encompassing and meaningless.

Declaring war is also declaring a state of emergency, which is a temptation to autocrats. Labelling the microbe as an ‘invisible enemy’ or an ‘invader’ can imply that those who carry it are also enemies or invaders. In America, the term ‘lockdown’, innocuous in the white suburbs, has the resonance of the New Jim Crow among communities familiar with mass incarceration, where locking down prisoners in their cells is the routine response to a prison disturbance. Lockdowns may provide some immediate safety from physical injury to prisoners but their intent is to protect the prison itself. In countries familiar with civil war and counter-insurgency, the rhetoric and physical attributes of lockdown, such as checkpoints, curfews, and neighbourhood searches, are reminders that there is a thin line between policing a pathogen and policing a hostile population. The warlike language means that advocates for democracy, equity, and justice are constantly at a disadvantage, as their dissent may be seen as sabotaging the war effort.

The ‘war on disease’ is also a script for conquest. The European version was born exactly at the zenith of colonial ambition and still carries that imperial DNA, as a project for dominion over the territories of the globe, its peoples and its microbes. Its language is male, white, and controlling. It promises mastery over nature, setting our bounds wider still and wider, making our mighty technologies mightier yet. This is perhaps its most insidious implication: a victory over a disease is a validation of a benevolent (for us) Anthropocene.

Fighting words also serve politicians whose agenda is dominating the day’s headlines. In the last few years, legal-rational forms of public authority have yielded to charismatic, transactional, and disruptive styles of governing. For such politicians, the narrative is the solution, and science should be strictly in its service. Donald Trump was an exemplar. Transactional politicians such as he are tactical fighters, not strategic war planners. They relish political combat but don’t want the institutional discipline of organizing a war effort, and choose their fighting talk accordingly. Like others who deny or disregard scientific method and data, Trump did so against a background of unquestioned faith in other things – in his case, winning through acts of will and rhetoric. And while he considered face masks and restrictions on travelling and congregating as something between an annoyance and a conspiracy, he believed fervently in the catechism of the magic bullet, perhaps even more so than his scientifically literate political peers.

The main topic of this book is the construction and reconstruction of the Euro-American ‘war on disease’ narrative. I chose three historical pandemics for this purpose. Cholera is the case in chapter 2. This is where Europe’s war on disease began two hundred years ago, as a handful of metaphors, images, and practices. Of these the most consequential was the concept of policing the contagious, inherited from the plague and applied to cholera. At that time, the idea of a ‘war’ that resembled a real war would have been fanciful. That changed, and by the end of the 19th century a firm storyline took shape. Its first element was the plan of campaign – an assemblage of instruments for social control, which we could distil into a slogan: lookout, cleanup, and lockdown. ‘Lookout’ was alertness for cases, especially sick travellers, and detecting the pathways of disease spread. ‘Cleanup’ was sanitation: personal cleanliness, fresh air, clean drinking water, draining stagnant water in which insects might breed, controlling vermin and disposing of sewage and rubbish. ‘Lockdown’ was quarantine, sequestration, isolation, and curfew – policing people and pathogens. The next operation in the war story was conquest and dominion: the project of exploring, naming, classifying, and controlling the entire surface of the planet and every living thing upon it, from microbes to human beings to forests. In short: imperial exploration, expansion, and subjugation. The final element was the technology for victory, when microbiologists began crafting ‘magic bullets’ that could hit those invisible enemies.

Chapter 3 deals with influenza in 1918–19: a pandemic that refuted civilization’s proudest achievements. It was a monstrous killer and, insofar as there was a fight against it, influenza won. The Great War created and transmitted the virus, public health measures worked only at the margin, and medical science found neither cure nor vaccine. But the script served its purposes: governments continued to mobilize armies and send them to the warfront and citizens kept faith in biomedicine. The failure and deceit over influenza were too big to contemplate, and the pandemic remained untold history for two generations. Virulent influenza was our social taboo, but our virological totem: fear of its return energized pandemic preparedness in the 21st century.

The war on disease was refashioned after World War II, when international health campaigns against smallpox and polio registered huge gains. The successes were such that the medical academy was ready to declare victory over infectious diseases altogether. This was hubris. In chapter 4, I turn to a momentous setback with a surprising twist: HIV/AIDS. The story of the global response to this pandemic is inspiring – and also confounds the standard narrative. A coalition of people living with HIV/AIDS and a wider community of carers, physicians, and global health advocates pursued an agenda of health and human rights, which surpassed expectations on both counts. They sometimes used fighting language, but in the different sense of a struggle for liberation and emancipation. AIDS was exceptional, however. For other ‘emerging and re-emerging’ infectious diseases, the ‘war on disease’ was reinvented. This is the focus of chapter 5. After the millennium, fears of unknown or resurgent pathogens that threatened ‘Pandemic X’ re-militarized pandemic preparedness. Advocates for global health security found a storyline in common with the war on terror. Our fears and efforts were targeted on individual germs, and not on the ecologies that generate them or the society and economy that enable them to spread.

The history of the ‘war on disease’ narrative is an ironic commentary on medicine and warmaking. Microbes have decided the outcome of wars, though generals on the winning side don’t often acknowledge it. Military doctors have been leaders in the technologies of controlling contagious diseases, and their medical victories have enabled armies to complete conventional forms of conquest, such as expanding empires. Military scientists have also created monstrous bioweapons in the laboratory. Pandemic preparedness intersects with biosecurity risks when a laboratory engineers a virulent pathogen to discover more about the pandemic threats we may face, with the aim of better understanding and counteracting them. A pathogen like this may escape through a laboratory accident (which has happened a number of times, though scientists prefer not to talk about it, as described in chapter 5), and once an academic journal has published the genetic codes for a virulent virus, it’s possible for a malevolent scientist to repeat the feat.

Covid-19 was the least unexpected pandemic in history. Scientific and institutional preparations narrowed the uncertainties of a new pathogen to a span that should have been readily manageable. And indeed the development of vaccines in record time is testament to scientific expertise backed by public money. The best-laid plans were confounded, however. It turned out that the main agent of radical uncertainty was not a new and inscrutable microbe. Instead it was Anglo-American political leaders whose doctrine of disrupting institutions, including science, made the pandemic ungovernable. At a cost of hundreds of thousands of dead and millions impoverished, this has had the modest virtue of showing that the ‘war on disease’ is a humdrum script that cannot guide political action.

I would have liked to have drafted a new playbook for emancipatory public health in the Anthropocene, but this book concludes with something more modest: an appeal that it’s necessary to talk about this. There are hopeful openings, such as ‘One Health’, which unifies public health with animal health and environmental sustainability, and ‘people’s science’ approaches to disease control. At the moment, however, these remain minority agendas.

For now, people who work for democracy, human rights, liberal education, environmental sustainability, and similar goals – citizens, activists, elected officials, and the like – are bewildered as a pandemic arrives. They shouldn’t be. For English-speakers at least, their problem begins because the English language doesn’t give them a firm mental grip on the crisis. Our vocabulary is deficient.

The point of etymological origin is the word ‘epidemic’. This was first used by Hippocrates 2,500 years ago. In classical Athens, an ‘epidemic’ referred to an episode of sicknesses among the people. The people (‘demos’) was not today’s ‘population’, it was restricted to free male citizens. Sicknesses included all diseases occurring at the time. In the 14th century, ‘epidemic’ got attached to named diseases, especially plague. Often used interchangeably with the noun ‘epidemy’, in the early 19th century, ‘pandemic’ was used for a geographically magnified epidemic. Cholera was its archetype. At first, it had a sibling ‘pandemy’ as well. With the demise of ‘epidemy’ and ‘pandemy’, the English language lost the distinction between a societal crisis and a much higher number of cases than normal of a disease.¹⁴ ‘Pandemic’ is best used as an adjective, to qualify a disease – thus, ‘pandemic influenza’ or ‘pandemic Covid-19’. Were these old words to be revived, speaking of the ‘Covid-19 pandemy’ would make it clear that we’re referring to the entire societal crisis. This crisis includes all the other health problems that worsen when hospitals are overwhelmed by cases of one disease, along with the psychological distress, the losses of livelihoods, and strains on communities. The concept ‘pandemy’ could also be stretched to include ecological and societal pathologies that cause pandemics. I won’t use the word ‘pandemy’ in the chapters that follow, but it will remain in the background and I will return to it in the final chapter.

Democrats and social activists don’t have many tools to steady them in the pandemic storm. They can look to historians’ accounts of past pandemies (here the word doesn’t sound so quaint), but each one of those is so distinct, and the context in which they struck is so different, that there doesn’t appear to be much of current relevance. Reading Boccaccio on the plague in Italy, or Daniel Defoe’s account of the London plague, or reconstructing the devastations of small-pox in 16th-century Mexico, provides a stock of anecdotes and intriguing echoes but not much more. This book is also a history, but my guiding principle is that each pandemic is a shock and disruption of its own distinct kind. Insofar as there’s a pattern, it’s in the political response.

We can turn to social medicine and its analysis of inequalities in health care provision and health outcomes, and the importance of socially engaged and culturally sensitive public health.¹⁵ Each pandemic reveals inequalities in health, housing, income, and political access. HIV/AIDS shone a light on other injustices: discrimination, stigma, sexual and gender-based violence and exploitation, and repressive policing. With Covid-19, selective vaccine provision may soon become the greatest ever inequality in health care history. Social medicine also illuminates the frightening levels of public distrust in medical expertise. For too long, health experts and authorities took public compliance for granted. Today, ‘trust me, I’m a doctor’ no longer convinces. Minorities and formerly colonized peoples have had good reasons to distrust the official health apparatus, which too often treated them with contempt. Western publics are growing suspicious of medical authorities, to the extent that mass vaccination – the single greatest success of public health – is in serious peril. Vaccination prevents epidemics when it delivers herd immunity, which is usually achieved when about two-thirds of the population have natural or acquired immunity. Vaccine distrust means that America and some other countries may not be able to reach that threshold for Covid-19. Most health scientists just want these problems to go away: the facts alone should suffice to convince. In her book on this subject, Stuck, Heidi Larson takes a different view. She provocatively observes that ‘vaccine rumors are here to stay, but that is not a bad thing’.¹⁶ That’s because medical scientists are compelled to join the public debate – a debate that will need to include questioning the role of immunological technology in the Anthropocene. Expedited comprehensive immunization is akin to building higher seawalls to protect coasts from the rising oceans: inescapable but limited.

The citizen science movement has been hugely accelerated by Covid-19. Never before have so many people become epidemiologically numerate so quickly. But this hasn’t kept pace with a fast-raging pandemic. The most encouraging examples of activists setting an agenda for pandemic response are from HIV/AIDS – which I will discuss in chapter 4 – but that was a slow-burn pandemic and it took several years for the affected communities to organize and make their case, and for the health authorities to listen. In the case of Ebola in west Africa – discussed in chapter 5 – the mutual learning was much quicker and the anthropologist Paul Richards observes that the epidemic was overcome when ‘communities learnt to think like epidemiologists, and epidemiologists to think like communities’.¹⁷ This is a crucial example of public health as a people’s science, and Richards encouragingly observes that it can happen rapidly.

Joint learning by epidemiologists and the public runs into several problems with the ‘war on disease’. The first is that war leaders give orders and expect obedience.

The second is that control instruments demand discipline. For contagious diseases, it’s a brute fact that measures such as stopping travel and screening or quarantining travellers, and rigorous surveillance of individuals’ activities, can stop transmission. In European history, building and legitimizing that apparatus of control was part of creating the state.¹⁸ Human rights law allows for emergency public health to overrule civil and political rights.¹⁹ The tensions between disease containment and personal freedoms are real, but are easily exaggerated and politicized, especially when narratives of control and fear chime with authoritarianism and xenophobia. Measures to control infectious diseases don’t need to be coercive and comprehensive. The opposite is true: they work best when they are consensual and precise – the two go together because contagion control is best done locally by ordinary people. The most encouraging examples of joint learning by communities and epidemiologists are in the global south or among minorities.

This points to a third problem with the ‘war on disease’: its imperial lineage. Rich countries typically don’t have the humility to accept lessons from former colonies. An African slave introduced smallpox inoculation to North America in 1720 but his contribution isn’t widely known and his real name isn’t known at all. Recent Ebola outbreaks were overcome by African people’s science, and one of the saddest episodes in Covid-19 policy is that African countries have not valued that experience and have instead regressed to copying centrally planned European lockdowns, which are hopelessly ill suited to their circumstances. Again, we can also learn from AIDS. Many of the most effective HIV prevention programmes were set up in partnership with injecting drug users and sex workers. We would all be much safer if we could respect ‘the wisdom of whores’.²⁰

Social activists and social scientists are unprepared for pandemics. They don’t even have a paradigm to shift. What they do – consult, reflect, discuss – seems like a leisurely enterprise suited to a less urgent time, that is, afterwards. Implicitly, we accept centrally directed, expert-designed, and coercive measures because we assume they are a stopgap until biomedicine delivers a definitive cure. The technical term for behavioural and social measures is ‘non-pharmaceutical interventions’, or NPIs – which betrays their second-level standing. But these NPIs are the response, and because they are necessary and painful, it is important to have public discussion and consent. Can this be done fast? A year after Covid-19 appeared, it’s evident that it should have been done at the beginning.

Those who believe they have ‘won’ a war are least likely to appraise candidly why they have prevailed, crediting successes to their skill and perseverance and not to their enemies’ blunders – and still less to extraneous factors such as that under-appreciated arbiter of the battlefield, disease. Winners can be slow learners. This book also shows how historic ‘victories’ in the ‘war on disease’ have led to hubris or amnesia. Biomedical advances such as vaccines deliver genuine public goods, but – as virologists today appreciate – that is no cause for complacency. Which brings us to our last and biggest challenge.

The ‘war on disease’ also doesn’t speak about the ravages of ecological destruction and the resulting disaster for the health of living things, including us. It makes microbes into enemies to be eliminated. Our conquest and dominion over the planet are on course to be the ultimate Pyrrhic victory. This is the calamitous Anthropocene: the result not of people as such, but of the organization of resource exploitation, manufacturing and agro-industrial production, massively concentrated human habitation and accentuated movement. Ecologists have been warning that deforestation and loss of wetlands are disrupting the habitats of bats, monkeys, and wild geese, risking more and more viral spillovers, and that industrial farming and urbanization are creating dangerous ecologies where viruses adapt more rapidly. Doctors have also been warning about the fast-approaching post-antibiotic era brought about by the reckless overuse of antibiotics, both by over-prescription by physicians and pharmacies, and in industrial livestock and fish farming. The new global ecology has been created by us but microbes are the quickest to adapt to it. The political-economic logics at work here are similar to those driving global heating and the climate crisis: the political clout, money, and readiness to lie and cheat by the corporations that profit from over-exploiting the planet are more powerful than the counter-pressure for responsible stewardship. Today, medical scientists and epidemiologists are joining environmental scientists in insisting that it isn’t enough to identify and eliminate the next microbial culprits for contagious disease: we have also to stop the ecological devastation that is generating them. Each pandemic pathogen has forced science to think more deeply about the nature of disease. So too it compels us to think differently about how society is organized and politics is run. Pandemic Covid-19, along with its causes and social crises, is a chance for the urgent and inescapable task of rethinking Homo sapiens’ place on this planet that we have too long considered ours.