The following is adapted from the Epilogue of the book

Before any of us had heard of COVID-19 or realized the world would change (or revert) so suddenly, Jonathan Katz wrote the foreword of this book. In many ways, it is an eerily prescient choice of epitaph evoking the now all too apparent issues with testing and quarantine. Katz describes epidemics as virulently splintering and cleaving. This virulence may be biological, like the transfer of a virus through sex, the invisible film of a touched surface, or a breath of air. Yet epidemic diseases are experienced mostly through their social virulence and exposure of pre-established hierarchies. Indeed, outbreaks are never egalitarian in their impact, and never cleave in the same way. People assumed to be “infected” or possessing the insidious power to “infect” can evoke violent fears that clutch to old prejudice. As Katz wrote, “beneath that lies an all too human desire to locate, name, enumerate and then excise the unknowable threats that haunt all existence.”

With anxious eyes we look ahead, but we should also look back. Our current age of infectious diseases, including HIV/AIDS, Ebola, Zika, and those caused by the coronaviruses (SARS, MERS, COVID-19), can be blamed on greater and faster movements of people. Since the early modern era, history recorded two previous periods that were characterized by an increase in terrifying plagues. They have marked a significant stage of human migration and globalization. When the first Europeans and enslaved Africans crossed the Atlantic Ocean in the late fifteenth and sixteenth centuries, they unknowingly carried with them a set of destructive diseases that depopulated the Americas. The specific diseases that killed millions of indigenous peoples are uncertain; most probably they are smallpox, measles, and influenza. Europeans took advantage of the devastation to win wars, enslave, occupy, and settle.

Beginning in the 19^th century, revolutions in industry and transportation set into motion another wave of mass migration. Rapidly evolving urban centers became harbors for infectious diseases, among them cholera, typhoid, dysentery, tuberculosis, and influenza, that depended on a steady stream of mostly poor and desperate migrants for dispersal. This second period of epidemics helped create more activist governments and a wave of public health measures. Such changes were facilitated by an increased understanding of disease-causing microorganisms and revolutionary drug discoveries. Modern medicine and public health have vastly improved control over infectious diseases, reduced mortality rates, and extended life spans, especially among the wealthier countries.

The third and current era of new epidemics began with the AIDS pandemic in the 1980s. Environmental degradation, poaching, wildlife trades, and hyper-globalization increasingly provide fertile grounds for outbreaks that are less likely constrained to nations or regions. The viruses causing HIV/AIDS, Ebola, Zika, SARS, MERS, and COVID-19 have “spilled over” from animals to humans, threatening global populations. As more vectors carrying pathogens invade new hosts, older and more familiar scourges such as yellow fever, malaria, and dengue fever dramatically extend their regional threat in part as a result of climate change. Additionally, a multitude of infectious diseases is becoming increasingly difficult to combat with our miracle drugs as microorganisms rapidly evolve resistant strains. We confront alarming questions: What may curb the dramatic rise of infectious diseases? How are we to address and mitigate the devastation they may bring?

COVID-19 painfully brings these questions into the public awareness, and many aspects of this unfolding pandemic reiterate the central message and findings of this book. Although SARS-CoV-2, the virus responsible for this disease, seems new and alien, it has a long evolutionary history. Coronaviruses are a large family of zoonotic pathogens (transmission from animals to humans) that are widely present in diverse bat and bird species. It is clear that they have been a part of human and other animal life for millennia. Some research suggests an even more ancient viral lineage with a common ancestor for coronaviruses dating back millions of years.[1] These viruses likely sparked epidemics in the past, some that historians might have “retrospectively diagnosed” as something else, like influenza.

As the current coronavirus pandemic so terrifyingly demonstrates, a virus is much more than a phylogenetic “curiosity.” The discussion of Ebola (chapter 13) vividly illustrates that the terror of an epidemic “should not be assumed to lie in the genetic mutation of the organism itself, but rather in the pathways we humans create for it.” COVID-19 is undeniably the result of biological and ecological processes, yet as is true in this pandemic and the other plagues described in this volume, social, economic, and political forces can facilitate or curb pathogenic development. While we may be far from understanding the biochemical and physical processes leading to this coronavirus infection, we experienced, early on, the tremendous impact cultural, economic, and political climates can have on its containment and treatment.

For example, fear of political repercussions prevented and delayed essential communications about the initial COVID-19 outbreak between the local and central governments in China, and subsequently between China and the international community. Similarly, in the early 1990s, AIDS killed hundreds of thousands in Henan Province, China (chapter 8). Corruption, deception, and inefficiency characterized government responses to the epidemic that were aimed to please Beijing’s political leadership rather than secure the health of citizens in the province. Thus, plasma collection stations were not closed, despite the known risks involved. A suicide epidemic of mostly young people in Oceana (chapter 2) presents another case where local health and healthcare were structured to serve larger, distant bureaucratic interests. In the 1980s, academics and state officials, blinded to the root causes of the deaths in unequal world systems and colonialism, used the tragedy to reinforce those systems. 

We witnessed the rapid global spread of COVID-19 with fear of economic repercussions dictating inadequate policies for its containment in the early stages of the disease. As a result of not following the advice for containment and social distancing from governments that dealt with the first wave of deaths from this pandemic, western societies have thus far experienced a higher fatality rate and will face far-reaching social, economic, and political consequences. Considerations that place economic profits over community health are often (if not generally) at the core of epidemic diseases. The pursuit of profit may give opportunities to pathogenic disease, and it can slow reaction when the trade-off is its containment over revenue. When afflictions are born from consumer habits and mass marketing that make multinational corporations or governments trillions in profits or tax revenues, the trade-off is almost impossible. By way of illustration, COVID-19 is taking many of its victims from people who suffer preexisting conditions, including complications from smoking, poor diets, and sedentary lifestyles. If the coronavirus is a killer, then “Big Tobacco,” “Big Food” and “Big Pharma” that mass-produce and manipulate people into habitually consuming their products are accomplices to the crime (chapter 9). Major corporations have used obfuscation to deny the science that exposes their role in driving epidemic disease (chapter 10). Similarly, opioids and guns claim millions of lives worldwide every year, because they have been so accessible and promoted by special interest groups vested with medical and political authority. 

Social repercussions and stigmatization of individuals (regardless of their infection status) began well before the World Health Organization declared COVID-19 a pandemic in March 2020. Politicians and pundits implied entire regions as “diseased” through labels such as “Chinese virus” or “Wuhan virus.” We have since seen a rise in hate crimes against Asian Americans, attacks on foreigners in India, and increased antagonism between rural and urban populations. Hate is a familiar feature of epidemics, as in the discussion of incarceration and sterilization policies directed at leprosy patients in Japan (chapter 3). Behavior protocols are also less successful when patients are subject to bias, judgment and discrimination, factors directly linked to increased HIV transmission rates in Latino gay communities (chapter 5) and African-American women experiencing addiction, violence or homelessness (chapter 6). Nevertheless, stigmatization already complicates the tracing of those infected with the coronavirus disease. COVID-19 equally reveals how poverty and race expose vulnerabilities in disproportionately contracting the disease, in the unequal access to healthcare and treatment, and the drastically disparate survival rates. This volume provides useful and relevant analyses of how epidemics impact marginalized groups (due to culture, race, gender, class, sexuality, and region) and discusses alternative and promising treatment strategies to counter these effects, as exemplified in community-based participatory research.

The discussions in this volume illustrate the complex web of knowledge production, socio-economic conditions, and power relations that control the fight against epidemic diseases, particularly in the initial response and early phases of drug development (chapter 7). What has become abundantly clear, however, is that an acute international shortage and the lack of foresight to create sufficient national emergency stockpiles of basic protective gear are now killing front-line health workers. This is rather incomprehensible given our recent experiences and unpreparedness with Ebola in Western Africa (chapter 13) or pandemic influenza. In fact, some of the wealthiest nations appear as helpless in protecting this crucial first line of defense in the case of COVID-19 as we were with SARS in 2003 and Ebola in 2014.

COVID-19 provides another instance of how the physical and ideological worlds are invariably linked. In this pandemic, like others, nature and society interact to create, sustain, transform, or contain the disease. As we live (or partly re-live) this pandemic, few would argue that one discipline alone can or should make sense of it. It certainly commands the broadest of approaches, an openness to ideas, and far-reaching collaboration of experts from across vastly different fields. In this volume, we have called this approach radical interdisciplinarity.

We contend that identifying, surviving, or controlling epidemics requires more than a collection of diverse (autonomous) disciplinary insights. Instead, we should create conceptual connections and integrate knowledge. For example, a collaboration of research in microbiology, immunopathology, clinical epidemiology, genetics, and mathematical modeling to provide both the knowledge and technology for a vaccine. We also depend on political scientists and experienced diplomats to guide us at a moment that, in the words of United Nations Secretary-General António Guterres, “has no parallel in the recent past.” Policy decisions to address this crisis need to be informed by the critical insights historians can provide beyond the recent past. What can we expect to see in an increasingly interdependent and hyper-national world? At a time when we move more rapidly towards an ever more virtual world in which the existing inequalities of the real world may be amplified? Such questions matter for sociologists. They are equally relevant for psychologists who study human reaction in the face of shared external threats. Additionally, artists, linguists, and behaviorists collectively contribute to our understanding of the many diverse impacts social distancing may have: through the creation of images that give shape to shared meaning and by analyzing actions that are expressed within norms.

A global phenomenon requires a global response. If we embrace open borders, affordable travel, and global supply chains, then societies will have to make tough choices by somehow balancing security with liberty. This book draws attention to just how precarious and devastating these decisions can be. COVID-19 already evokes a climate of fear in which everyone can be seen as a potentially infectious body. Reminiscent of other epidemics, it can turn people and countries against each other, intensify ideological divides, deepen racial and class tensions, and reverse social, economic, and political progress around the world. Still we are witnessing extraordinary acts of heroism in the COVID-19 pandemic, in particular doctors and nurses struggling to save lives when a lack of simple protective gear endangers their own. As in other crises, there is potential for unity as grassroots volunteers, billionaire philanthropists and nations are coming together to provide services and goods.

Pandemics eventually end. Today, this may occur within globally interconnected scientific and laboratory systems that share scientific knowledge. Nonetheless, its implementation requires international norms and efforts, as is the case with vaccination and therapeutic protocols. We have learned from the recent past that success is rarely the result of a teleological march of scientific progress, but rather depends on multiple institutional forces interacting. “Success” may be fully containing pathogens (e.g., smallpox), transforming them with therapeutics into far less deadly diseases (e.g., HIV), and mitigating and monitoring seasonal or endemic threats to which we have no cure (e.g., influenza). To find appropriate resolutions, we need an interdisciplinary approach that focuses on innovative ways to address collective human suffering and encourages inclusive participation to identify and combat these formidable biosocial forces. This approach is not secondary to pathology nor independent from epidemiology. When we challenge established power relationships, redefine the hierarchical flow of knowledge production, and bridge the gap between the biophysical and cultural environments, we will affect some control over how epidemics shape us and we shape them.

[1] Joel O. Wertheim, Daniel K.W. Chu, Joseph S. M. Peiris, Sergei L. Kosakovsky Pond, and Leo L. M. Poon, “A Case for the Ancient Origin of Coronaviruses,” Journal of Virology 87, no. 12 (June 2013): 7039–7045. https://doi.org/10.1128/JVI.03273-12.

Video Interviews: The Shapes of Epidemics and Global Disease

Part 1: Andrea Patterson (co-editor)

Chapter 4: 'Epidemics of Inequity: Challenging the Racial Predisposition Hypothesis'

Part 2: Ian Read (co-editor)

Chapter 12: 'Tragedy at the Tropic of Capricorn: Nineteenth Century Globalization and Epidemiological Change on Two Sides of South America'

Part 3: John E. "Jack" Lesch

Chapter 7: 'Four Turning Points in the Treatment of HIV/AIDS'

Part 4: Lisa Crummett

Chapter 10: 'Industry’s Role in the Metabolic Disease Pandemic'

Andrea Patterson is Associate Professor of Liberal Studies at California State University Fullerton. She is a historian of medicine and public health with a focus on the intersections of gender, race and science. Her publications include journal articles and book chapters on African American health and healthcare under Jim Crow.

Ian Read is Associate Professor of Latin American Studies and Director of International Studies at Soka University of America, USA. His publications include journal articles and book chapters on Brazil, Mexico, and Central America, and the book Hierarchies of Slavery in Santos Brazil, 1822-1888 (2012).

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