Saying that the COVID-19 pandemic should not have happened will likely elicit one of two responses. Blaming China for initially trying to cover it up, or saying: “shit happens, this is speaking with the benefit of hindsight”. Appealing as these may sound, they are missing the bigger picture. The awful truth is that we have had this one coming for a long time.
Seeing this is a very hot topic, I think it is worth pointing out what you will not find in this book before diving into the rest of the review. Despite the title, you will not find all that much about the virological, epidemiological, or clinical details of COVID-19 and the virus SARS-CoV-2. As we are still in the middle of learning the biological details, you are better off just keeping a close watch on the news. That post-mortem will have to wait—although the primer Understanding Coronavirus provides useful basics on what we know so far.
The clue is in the subtitle. Debora MacKenzie writes this book from her unique vantage point as a veteran journalist reporting on infectious diseases for New Scientist and other outlets for over 30 years. With the world’s attention on pandemics, now is the best moment to draw our collective attention to her shocking tale of neglect and complacency in the face of warnings from the scientific community. This was true when Quammen wrote Spillover, and it still holds today.
“The clue is in the [book’s] subtitle […] now is the best moment to draw our collective attention to [a] shocking tale of neglect and complacency in the face of warnings from the scientific community.”
Judging by what MacKenzie describes here, it has been a perfect storm of various factors that got us to this point. There was a surge of optimism in the 1970s: we eradicated smallpox, we had vaccines to prevent childhood diseases, and antibiotics stopped all sorts of harmful bacteria. A leading medical textbook at the time even declared the future of infectious diseases to likely be very dull. Research departments were downsized as funding dried up. Public health stopped being a state-funded public good as the medical industry was swept up in the wave of privatisation of the 1980s. And networks for research and disease monitoring in developing countries were cast off as excess baggage from colonial times. In short, high on its medical triumphs, the world grew complacent.
But our victory was short-lived.
Ever since AIDS went global in the 1980s, disease experts have been trying to predict what might be the next big threat. We all know of the rise of antibiotic-resistant bacteria, but we also have had plenty of viral near-misses, such as Ebola, Zika, SARS, and MERS. Seeing the relevance of the latter two—they are both caused by coronaviruses—MacKenzie covers their outbreaks in detail. And then there is a whole chapter on flu, the annual recurrence of which has become so routine that we have stopped calling it a pandemic. Next to straightening out the misconception that COVID-19 “is just another kind of flu”, this is relevant because what little governments have in the way of pandemic preparedness plans is based around flu outbreaks. And those prominently do not recommend containment measures: pointless for the fast-moving flu, but relevant for COVID-19.
“[…] MacKenzie asks: what about traditional Chinese medicine? Both horseshoe bats, which carry coronaviruses, and their faeces are ground up wholesale and used to, for example, treat eye infections.”
This is the background against which warnings have been issued and, by and large, ignored. The World Health Organisation (WHO) has had a list of the viral Most Unwanted for years, prominently mentioning coronaviruses. Disease experts, reporters (MacKenzie amongst them), and writers of popular books have sounded the alarm for years. But hey, we have had enough of experts, right? If that was not enough of a slap in the face of science deniers, she ruthlessly despatches some harmful conspiracy theories (no, this virus was not brewed up in a laboratory).
Before getting to proposed solutions, MacKenzie dives down a few rather relevant rabbit holes. One is a very interesting chapter on bats. Bats host numerous viruses that can jump to humans, so they warrant close monitoring. MacKenzie issues a plea to not shoot the chiropteran messenger: certain groups are important pollinators. Plus, and this will not go down well with some but is something I appreciated, human overpopulation and the accompanying encroachment into wild habitats are the root causes here. She dispels as a red herring the idea of pangolins as an intermediate host. But most interesting of all, she casts a shadow of doubt on the whole bushmeat and wet market story. Yes, bats are eaten in parts of the world, but they are usually larger fruit bats. Instead, MacKenzie asks, what about traditional Chinese medicine? Both horseshoe bats, which carry coronaviruses, and their faeces are ground up wholesale and used to, for example, treat eye infections. Next to that potential infection pathway, it involves catching and handling bats. So far this is speculation, but these are reasonable questions to ask. One of the things I really appreciated in this book is that MacKenzie does not mince her words and is not afraid to broach contentious topics.
The other seeming rabbit hole is that of the complexity of our societies. What if a more lethal pandemic emerges? This is a short trip into the science of complex systems, feedback loops, tipping points, resilience to shocks, global supply chains, and, ultimately, the possibility of rapid collapse. Oh, and, depending on your point of view, a (un)surprising list of typically undervalued and poorly paid jobs that actually keep society running.
“the most important lesson […] is recognizing that profit-driven market forces cannot deliver new vaccines and antibiotics. “
These two topics return in the extended list of seven lessons for the future with which MacKenzie sees the book out. Most of these involve changes at the international level. What we do not need now is blame games. What we do need is more openness and cooperation regarding disease surveillance. Despite some criticism of the WHO here, she also highlights just how limited their budget is, and how their hands are tied due to the sovereign rights of nation-states that can simply hide information and refuse health inspections. We need more preparation, both in the form of research and stockpiling of supplies. We need to recognize systems complexity and accept reduced efficiency (and thus increased costs) to allow more redundancy and resilience in global supply chains. But the most important lesson, I thought, is recognizing that profit-driven market forces cannot deliver new vaccines and antibiotics. This is not about “evil corporations”, it is simply that the risk of failure and the frequent lack of return on investment work against us. This is why we have governments that fund public goods.
MacKenzie admits that COVID-19, written as it was in a mere two frenetic months, is somewhat rough around the edges. Personally, I think illustrations would have helped to explain certain biological details that she presumes understood, and an index would have been useful. But given the circumstances, their omission is perfectly understandable. What the book does deliver is a perfectly-timed, intriguing, and revelatory story of the dangers of ignoring science. And for a debut book, this is all the more impressive.
In closing, you might wonder how this book compares to The COVID-19 Catastrophe by the editor of The Lancet Richard Horton, the subtitle of which is very similar to this book. That book is shorter, focuses exclusively on the science policy failures, and leaves out a lot of the background provided here and elsewhere. It does, however, provide an insider’s perspective of someone who worked for the WHO.
Disclosure: The publisher provided a review copy of this book. The opinion expressed here is my own, however.
Other recommended books mentioned in this review: