Two books about diseases and public health

I’ve mentioned a few times that my research focus during my MA was disease (specifically rabies) and the Victorian novel. I’m still very interested in diseases in general, especially how we construct narratives of disease and how these narratives—often deeply ingrained—influence our ideas about public health. Old (research) habits die hard: whenever I see a new cultural history of disease come out, I buy it. And that’s how I came to have Eula Biss’s On Immunity and Steven Johnson’s The Ghost Map sitting unread on my shelf. I packed both for a vacation last month. I know, I am great at picking beach reads.

onimmunityAs its title suggests, On Immunity is an examination of the idea of immunity. Biss was inspired to write the book after she had a baby and faced the question of whether or not to vaccinate him. Biss did vaccinate her son, as she had always thought she would, but she was surprised by the amount of fear she felt herself, and encountered in others, when she talked to other mothers about this choice. She started thinking about vaccination, and the idea of immunity, and how vaccines developed in the first place, and this strange cultural moment we live in where people are opting out of vaccines that have saved literally millions of lives in the past hundred years. (I’m wildly pro-vaccine, in case that wasn’t clear before.)

In On Immunity, Biss interrogates the metaphors and myths we use to describe immunity. Vaccination is an expression of fear, whether it is fear of something concrete and relatively preventable such as death by measles, or something far more intangible, such as the fear of death itself. But the anti-vaccination movement is also based on fear: fear of the government, fear of Big Pharma, fear of injecting the unknown into your body. If skin is a barrier between our bodies (our selves?) and the outside world, then vaccination penetrates that barrier—all in the name of granting you immunity.  It does seem contradictory, doesn’t it? After all, vaccines contain the very viruses they are supposed to be protecting us from. The earliest form of inoculation against smallpox involved rubbing scabs or fluid from a smallpox patient into one’s own skin.

Biss understands this fear of vaccines on an individual level, but she also points out that in the case of infectious disease, our bodies may not be solely our own. Herd immunity, which means the general immunity to a particular disease in a population of people, depends upon people getting vaccinated. As the recent resurgence of diseases like measles shows, it only takes a few nutty people to threaten herd immunity for everyone. And there are people who can’t be vaccinated for health reasons (ex. allergies) or who have compromised immune systems (ex. cancer patients). What is our responsibility to public health? Are we required to be vaccinated so that others won’t get sick? Health is assessed on an individual level at our yearly physicals, but our own physical health depends in many ways upon the health of our community, especially when it comes to infectious diseases.

Victorian London learned this the hard way during the 1854 Broad Street cholera outbreak. Cholera was the scourge of the 19th century, popping up every so often and routinely killing thousands of people per outbreak. (Cholera is still a problem today.) No one knew how it was spread until the Broad Street outbreak, but there were plenty of theories, chief among them the miasma theory. Simply put, back then, London stank. Lots of people crammed into tiny dwellings leads to lots of waste, and Victorian Londoners weren’t so great at managing their sewer system (or, um, having one). The air in London smelled pretty bad. Many respected officials and doctors believed that diseases, including cholera, were spread by this “bad air,” aka the miasma theory.

A cartoon from humour mag Punch depicting the Thames, the source of the stinky air. Source.

An 1858 cartoon from humour mag Punch depicting the Thames, the source of the stinky air. Source.

Along came John Snow, a doctor who was already notorious for pioneering the use of anaesthesia. When an outbreak of cholera occurred in his neighbourhood in Soho, he mapped the instances of disease and traced them all back to one water pump, where he found that the water supply had been contaminated by one household suffering from cholera. Feces from that household made its way into the water supply, and the disease spread through the water supply into the surrounding houses with devastating effects. Snow was one of the first epidemiologists, although he never got the credit he deserved and died without having his theory accepted by the medical establishment of the day.

ghostmapThe Ghost Map tells the story of this outbreak and Snow’s investigations. It is well-researched and fascinating, like a thriller where the villain is invisible and also causes a lot of diarrhea and suffering. I wish, though, that Johnson had spent more time investigating the cultural context of cholera and how Victorians thought about disease. The idea of the social body is an important one to add to this discussion, especially because it still has relevance today (see Biss’s questions about whether we owe it to our neighbours to get vaccinated). And how did Victorians approach infectious diseases like cholera, tuberculosis, and typhoid fever?  How did they write about disease in their newspapers, depict it in cartoons, confront it in their fiction? They had limited medical knowledge of pathogens and germs, but they were beginning to break through in other important areas (microscopes, the idea of inoculation). It seems to me that this conflict gave rise to many inaccurate but interesting depictions of diseases that suggest a society obsessed with health, illness, and infection. The Ghost Map could have benefited from some discussion of these questions.

In some ways, we’re still Victorians. Just like them, we’re obsessed with health. Also like them, and other humans throughout history, we still infuse our disease-related language with metaphor. As Biss points out, the way we talk about many diseases is steeped in the language of battle: so-and-so “lost her battle with cancer,” white blood cells are “armies” that keep our bodies safe from infection. In our struggle to understand our bodies, we rely on metaphor to give shape to our invisible inner workings. As Susan Sontag argues in Illness as Metaphor (a must-read for anyone interested in these issues), our dependence on metaphor leads to moral judgments about certain diseases. Sontag looks at consumption (tuberculosis) in the 19th century and cancer in the 20th and concludes that our disease metaphors lead to a kind of blame the victim mentality. For the Victorians, all kinds of diseases could blamed on emotional repression or moral failings. Countless novels feature women who are forced to bury their feelings and are soon wasting away from some nameless ailment. Men in the same novels who are “weak” and prone to drink inevitably end up dying of their own unnamed illness. And not a lot has changed in how we talk about illness. In 1978, when Sontag wrote Illness as Metaphor, one alternative cancer treatment involved psychotherapy to help find out what part of your personality brought cancer upon you.

Likewise, our current obsession with trends like “clean eating” often leads us to assume that people who don’t eat chickens that were raised to believe in themselves and organic blueberries watered with angel tears are doomed. There is, of course, a lot of privilege involved in these assumptions we make about health and wellness. The point is, a disease is never just a disease.  It’s a battle we must fight. It’s a statement about our incomes, the food we eat, the amount of exercise we get, the kind of sex we have or the number of partners, the amount of alcohol we drink. It’s a sign of our most private defects, writ upon our bodies for the whole world to see.

And why do we think about disease this way? I don’t know, but I suspect it’s because we have a hard time accepting that our bodies are, ultimately, out of our control. We can eat all the happy chicken we want and avoid pesticides and wear a mask on the subway, but we’ll still get sick, especially if we live in large urban centres (and increasingly, many of us do). There are precious few things we can control about our bodies. All the more reason to get vaccinated.

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Quick Project Update

Not only have I not finished any other books on my list, I’ve actually purchased more (yes, I have a problem) and therefore have more to add. I’ve been reading, but I’ve been reading library books.

I’m still in the middle of A Tale of Two Cities, and as much as I have been a cheerleader for Dickens in the past, I am finding it quite boring. Just being honest! And no one is more willing than me to suffer through Dickens’s paragraphs about poor orphans and saintly girls with golden locks in order to get to his flashes of brilliance: spontaneous combustion, houses that fall down around their occupants, Wemmick’s castle. The opening sentence of Two Cities, reproduced for your reading pleasure below, is, of course, wonderful, but the rest is slow going.

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way – in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.

But what a sentence! Right? Doesn’t that describe every era since the dawn of time? Isn’t that what we all think about our own times—that everything is terrible and confusing but also wonderful and new? There is no other writer quite like Dickens. And so I’ll keep going with A Tale of Two Cities (and, eventually, the other two Dickens books on my shelf… oh dear).

One thing I’ve been thinking about is how people encountered this novel originally. It was published in 1859 in weekly installments in the periodical All the Year Round, run by (of course) Dickens himself, who was a true control freak. In a sense, the fact that I keep putting it down and picking it up again a week or two later is really how it was intended to be read. (OK, I’m reaching a bit here, but it’s kind of true.) In some of Dickens’s other novels that were published serially, you can really see the mechanics at work—chapters end with cliffhangers, but in the next chapter, the narrative begins in a different place or with different characters, to keep you reading for the outcome of that earlier cliffhanger. Sort of like what George R.R. Martin does in Game of Thrones and its sequels, really. Or like watching a weekly drama series on TV, a comparison that other, smarter people have already made. People today who gather around the office water cooler to talk about last night’s shocking episode of Mad Men or Homeland could just as easily be Victorians chatting to their neighbours about that week’s surprising installment of Little Dorrit. 

Dickens was a very market-savvy writer and knew exactly how to sell his own work, something that a lot of writers still aren’t very good at. (Fun fact: apparently A Tale of Two Cities is the bestselling novel of all time. I’m not sure if this is true—what about Harry Potter?—but it certainly could be true.) However, I’m having trouble tracing the marks of serialization in A Tale of Two Cities. So although I’m (sort of) encountering the novel the way that Victorian readers first did, I’m missing the sense of urgency and the typical structure, with lots of plot climaxes, that you’d find in a novel that was originally serialized. I wonder if it’s just my own disinterest in the subject matter and characters so far,* or whether Dickens had grown tired of relying on that same old serialization technique at this point in his career. I’m going to start paying closer attention to chapter openers and closers, to see if I can work this out.

* The novel is set in Paris and London during the build-up to the French Revolution. It’s one of two works of historical fiction by Dickens, all of his other novels being set in the period in which they were written or thereabouts. Two Cities also features fewer characters and plotlines than a typical Dickens novel. I love the sprawling narratives and dozens of characters you’ll find in something like Bleak House, so I’m finding it more difficult to get into a book focusing pretty closely on two families and their closest associates. Dickens is also often criticized for being something of a caricaturist, rather than developing characters who feel like real people. There’s some truth to this, but especially so in Two Cities so far, I think. Lucie is very innocent and very beautiful, and her father is very wronged and very damaged, and the Defarges are very inscrutable and very sinister. Everyone is very something-or-other. So far, Sydney Carton is my favourite—mainly because he’s sarcastic but has hidden depths. He feels the most like a real person to me.

Anyway, I’m still reading from my list! Just very slowly.