Book Reviews: The Science and History of Studying Epidemics

Note: This post consists of the following two sections:

  1. An essay version of the reviews, written for my library newsletter.
  2. A more detailed version that explains more about my motives and offers more details, book-by-book. I intend to add updates at the end as I review more of the genre. If you intend to read this section, you can probably just skip the first section as redundant.

 


HSL NEWSLETTER VERSION 

Book Review: The Science and History of Studying Epidemics

by Carl V Phillips, PhD

Epidemiology (the study of health outcomes and their causes) is the science that you most often encounter in the news and that has the most immediate impact on people’s lives. But readers with a taste for science books probably understand particle physics and population genetics better than they understand epidemiology. There are just not many books, and most of them are bad. I decided to journey through the HSL stacks to identify books about the science and historical development of epidemiology that would be useful to lay readers and that would be a good supplemental reading in an undergraduate class. While that history is not sufficient for understanding modern epidemiology, it is useful start. (The full version of this review plus more detail appears below (those reading a non-clickable version of this can use: bit.ly/PopEpiReviews).

The one sentence version of what I found: Read Patient Zero; solving the mysteries of deadly epidemics, by Marilee Peters (2014).

This seemingly causal book is a surprising gem. In a couple of hours, the reader can get a decent understanding of how epidemiology works. Both the history and science are refreshingly accurate. The book recounts the history of a series of infectious disease outbreaks from the 17th through 20th centuries, including the iconic stories of the development of pre-modern epidemiology (cholera in London, 1854; yellow fever in Cuba, c.1900). Along the way, it effectively leads the reader through the development of the methods for determining causes.

The book is positioned as “young adult” (YA; i.e., older children), so readers might find the plethora of sidebars and illustrations a bit annoying. But the sidebars are mostly genuine science lessons. The reader must also struggle through the YA physical features (“kids will never read a book on white paper, so better change the background color every few pages; also make sure to throw in a lot of pointless cartoonish graphics and goofy fonts”). It is kind of sad that such a good book has to be marketed in the category dominated by vampire romance fiction simply because it cannot be used as a doorstop. Readers of any age will learn far more about epidemiology from this book than they will from most of the doorstops out there.

The narrative prose style makes for pleasant reading without diminishing the educational value (assuming the reader does not mind some novelized descriptions of events, presented as if they were documented facts). A non-expert reader may not notice the precision with which important scientific points are described — simplified but still right, as opposed to the more typical sloppy and simplistic. The historical stories include memorable lessons in the importance of comparison groups (“controls”) when trying to detect elevated disease rates, in both the observational and experimental context. The attentive reader will learn the difference between descriptive epidemiology (statistics on health outcomes that are not focused on finding a particular cause) and etiologic epidemiology (attempts to identify a cause of an outcome).

There are only a few tiny factual errors in most of the book (see below for details), though I recommend skipping the epilogue and final chapter on HIV/AIDS, in which the earlier tightness and precision is replaced by what is unfortunately typical of the genre. (If you are interested in HIV/AIDS, read Shilts’s And the Band Played On, which is unfortunately not in the HSL collection.)

Other YA titles proved less impressive. Fatal Fever; tracking down Typhoid Mary, by Gail Jarrow (2015) and An American Plague; the true and terrifying story of the yellow fever epidemic of 1793, by Jim Murphy (2003) are about particular disease outbreak events, as is obvious from the subtitles. The similarity ends there. Murphy’s book is a lite version of history thesis, recounting a chronological series of events based on extensive research. Unfortunately, neither the historical events nor the presentation offer an interesting narrative arc or much scientific insight. By contrast, Jarrow’s book is little more than what contemporary newspaper readers would have learned in New York, c.1906. But the history and presentation make it a better story, about how epidemiologic investigators tracked down clues and drew scientific conclusions (though the lessons are not nearly as deep as Peters’s). Readers interested in history will appreciate how both titles capture the general historical environments of the day.

There is a fairly extensive subgenre of doorstops recounting moments in epidemiologic history. Inside the Outbreaks; the elite medical detectives of the Epidemic Intelligence Service, by Mark Pendergrast (2010) is a title that probably only a specialist would appreciate. It is a disjoint chronology of outbreak investigations, presented with minimal detail, and probably only makes sense if you already understand the science. One book to definitely avoid is the most recent in the genre, Get well soon; history’s worst plagues and the heroes who fought them, by Jennifer Ashley Wright (2017). The prose style can best be described as “rambling teenage Facebook post”, and it is the type of book that can easily leave the reader less well educated about the subject than before reading it.

You will be able to find my reviews of more books, as I complete them, below.

 


LONG VERSION

The following is a collection of short reviews of popular press books on the history of epidemiology, particularly infectious disease epidemiology and the infectious disease outbreak investigations that led to the development of the core methods of epidemiology. For those who are interested, I will probably be updating this periodically, appending new books to the end of post.

I started this project with an eye to finding a good supplemental text for undergraduate public health students, or perhaps even MPH students. The first on the list (Peters) is definitely the standout candidate for that, although some care would have to be taken to avoid insulting the students (as in: “yes, at a glance this looks like a book for children, but it really is an excellent analysis that was merely published in a juvenile package”).

I decided to start by working my way through the shelf of my local public library. It is perhaps not the most systematic search method, but it had its advantages: If I had started with an existing list of books on the topic (example), I would not have found Peters, the standout example in this collection, and would still have had to sort through some pretty bad books.

Note to readers finding this post via the essay version of this I wrote for the HSL library newsletter: All the books in the initial post are in HSL’s collection, as will be the first few updates. After that, I will probably stop restricting myself to that collection.

Patient Zero; solving the mysteries of deadly epidemics, by Marilee Peters (2014)

This seemingly causal book is a surprising gem. It reports the history of a series of infectious disease outbreaks from the 17th through 20th centuries, including the iconic stories of the development of pre-modern epidemiology (cholera in London, 1854; yellow fever in Cuba, c.1900). Along the way, it effectively leads the reader through the development of the methods that were developed to determine causes. The book is pitched as “young adult” (YA), and serious readers might find the plethora of sidebars and illustrations a bit annoying. But in this case, the sidebars are mostly genuinely good science lessons.

If someone wants to spend a couple of hours getting a decent understanding of how infectious disease epidemiology works, this book would be a very good choice. Both the history and science are refreshingly accurate and precise, setting aside the frequent novelized descriptions of specific events; these are generally plausible, but misleadingly presented as if they were documented facts. A non-expert reader may not notice the precision with which important scientific points are described — simplified but still right as opposed to the more typical sloppy and simplistic — but will probably still benefit from it. If you can get past the YA physical features (“kids will never read a book on white paper, so better change the background color every few pages; also make sure to throw in a lot of pointless cartoonish graphics and goofy fonts”), this is a genuinely educational book and a pleasant read.

I noticed only one glaring historical error, and it is an immaterial aside (the sinking of battleship Maine, which led to the U.S. occupation of Cuba and thus the important research on yellow fever, is generally believed to have been due to accident, not a Spanish attack as stated in the book). Peters can be forgiven for the one glaring scientific error I noticed because the error is also constantly made by infectious disease “experts” (much to the embarrassment of the field): She presents statistics for the percentage of people who contracted a particular infection that died. But these statistics are always wrong, quite often by a factor of a hundred or more. The count for the denominator (the number getting the infection) almost always is limited to those whose disease was so bad they ended up in a hospital or at least under medical observation. For each of them, there is almost certainly another person, or ten or a hundred, who got the infection but did not bother to seek medical care for their mild symptoms, or had no symptoms at all. Meanwhile almost no fatalities are missed. Thus when you read in the newspaper that “50% of those who contract infection X die”, the true figure is almost certainly closer to 5%, and perhaps 0.5%.

But that aside, Peters’s science lessons are good and tight. The historical stories include memorable lessons in the importance of comparison groups (“controls”) when trying to detect elevated disease rates, in both the observational and experimental context. The attentive reader will learn the difference between descriptive epidemiology (statistics on health outcomes that are not focused on finding a particular cause) and etiologic epidemiology (attempts to identify a cause of an outcome); Peters even labels the former, though avoids the latter big word.

The (Canadian) author’s attempts to shoehorn a few Canadians in important roles in these stories is a bit annoying but mostly amusing. Sorry, but Canadians are not among history’s important epidemiology researchers (and I say this as a someone who was once an epidemiology professor in Canada). More important, I suggest skipping the final chapter, on HIV/AIDS, and the epilogue. It was a terrible disappointment to watch this book descend from sharp and precise to the “at least one troubling error per page”-level more typical for pop science writing. (If you are interested in that topic, there must-read is Shilts’s And the Band Played On.) It is fairly clear Peters understood the development of epidemiologic thinking in the historical era, but really did not grasp where the field stood c.1980. Perhaps she just wanted to shoehorn the story into the narrative of “intrepid scientists forced to develop new clever research methods as they made their great discovery” that fit most of the previous chapters. It is not an accurate description of 1980, but it is still a good way to present the lessons from the previous chapters. So if you are at all interested in the topic, do read them.

Fatal Fever; tracking down Typhoid Mary, by Gail Jarrow (2015)

An American Plague; the true and terrifying story of the yellow fever epidemic of 1793, by Jim Murphy (2003)

These are both historical stories, about the tracking down, c.1906, and subsequent life of a woman who was a notorious carrier (an unaffected spreader of an infection) of typhoid, and of a yellow fever epidemic in Philadelphia. They are both classified as “young adult”, and while certainly accessible to the older minors who get called young adults, it is not clear why that should be thought of as the target audience. Both were reasonably interesting to read, but they were really just about the factoids of the respective stories, without much background, analysis, or depth (perhaps that is what makes them “young adult”).

Jarrow’s is the more interesting of the two. The text and pictures gave it the feel of a long-version of an “intelligentsia” magazine article. It tells the story of the titular character and a couple of experts involved in her case. But despite the author having expert credentials, there is very little insight offered into science, politics, or historical context. It is basically the story that contemporary readers of the newspaper would have known, which is not surprising since it is based mostly on a collecting information from those newspaper stories. There is ample opportunity for the author to seriously explore the ethical dilemmas (Mary was effectively imprisoned for the greater good, despite committing no crime) and the public policy challenges such disease carriers created. But Jarrow makes no attempt to address those points. Indeed, there is basically no context whatsoever beyond non-systematic references to the creation of sanitation systems. Even the interesting epidemiological detective work that Peters so effectively describes is presented as nothing more than a series of observations, with no insight into the scientific process. This is fine as a bit of history trivia, but do not expect any scientific or historiographic insights.

Murphy’s is a better proper history book, weaving together information from various original sources and presenting a series of documentable facts. But as such, it is not so interesting a read. Murphy offers no feeling for the arc of the disease and the surrounding experience, just a day-to-day series of reports about deaths and individual events. And then, all of a sudden, the next report is that the epidemic has abated. And yet, layered upon this standard dry historical thesis work are assertions of details that could not possibly have been recorded. Even if they could have been reasonably inferred as likely or plausible in spirit, the lack of hedging language (“the streets that day were probably filled with shoppers”) leaves the reader what liberties were taken with the potentially documented information (there is an extensive annotated bibliography, but individual claims are not footnoted). Murphy’s book is also almost devoid of science. There is a final chapter describing the eventual discovery that yellow fever is transmitted by mosquitos, a point covered much better by Peters. Indeed, it is pretty clear that Murphy did not really understand the science, given that in the narrative he dismisses (as “circumstantial evidence”) exactly the type of natural experiment evidence which Peters so effectively shows is at the core of epidemiologic science.

Inside the Outbreaks; the elite medical detectives of the Epidemic Intelligence Service, by Mark Pendergrast (2010)

This is an odd book, that I cannot recommend to any reader who is not already fairly knowledgeable and very interested. It is published as popular press, by a popular press author, but it seems to have a very niche appeal. It consists of an seemingly endless series of very short vignettes about what EIS (the outbreak investigation group at the U.S. CDC) did in response to particular outbreaks. The stories (which read like storified versions of dry official reports) and the minimal arc they form are just too thin to be inherently interesting. The scientific methods or cleverness represented in each is mentioned only rarely and in passing. The staccato brevity of the stories also means these always have the feel of a television detective show, where the only clues and observations that are presented are those that point straight to the already-known solution.

This strikes me as must-read for any student wanting to get one of the coveted postdoc positions at EIS. It is a somewhat interesting read for anyone who knows a lot about the subject and so can put the snippets in context, though frankly it is still tedious (I skipped over about half of the text). But for the average reader it seems rather like reading someone else’s “the story of our ancestors” book that was written for distribution at their family reunion. It is probably worth picking up if you find yourself interested enough to read fifteen books on this subject, but definitely not as the first or fifth.

Get well soon; history’s worst plagues and the heroes who fought them, by Jennifer Ashley Wright (2017)

One book in this genre that you should definite avoid is the one that, at the time of this writing, is on the “new nonfiction” shelf and that is being actively flogged for sales. It is utterly unreadable unless your preferred genre is “teenagers’ rambling Facebook posts”; while not classified for YA readers, it feels like it was written by a teenager. About one out of three sentences is a chatty and pointless aside, and one out of six ends in an exclamation point. Seriously! I kept expecting to see emojis. Granted that I write most of my work in a conversational style that not everyone likes, but Wright’s prose makes mine look like the height of formality.

I would like to be able to critique a few of the major substantive issue in her recounting or analysis. No doubt that someone whose job is writing magazine columns about sex and dating, and who apparently does not employ an editor, made a few major gaffes when writing about history and science. But the prose was simply too painful to get far enough to find more that stupid little errors. I should note I tried starting in numerous places, so this is not a case of a chatty introduction followed by getting serious. If suspect that if you extracted all the informative and useful bits of this book, the result would be shorter than Peters’s book (which is less than one fifth the length) and no doubt it would be far less systematic. Plus getting to the valid bits would inevitably expose readers to misinformation that will pollute their understanding. Then again, I suppose any reader who would choose a book about history and science whose author’s only apparent credential is having previously written Thirteen of the Worst Break-ups in History kind of deserves what they “learn”.

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