Contagious: Cultures, Carriers, and the Outbreak Narrative (review)

Communicable infectious diseases have played a central role in sociologic, political, demographic, and economic aspects of human society throughout history. In the modern era they remain a leading cause of death worldwide; in spite of scientific progress, new plagues and epidemics arise to challenge each succeeding generation. While some infectious diseases have a timeless coexistence with humankind (such as leprosy and syphilis, with reports dating back to Biblical times), others have seemingly been curtailed (such as smallpox and SARS), while new ones have emerged in our own era (such as AIDS and avian influenza)

In Contagious: Cultures, Carriers, and the Outbreak Narrative, Priscilla Wald, a professor of English at Duke University, takes particular interest in the sociologic sequelae of infectious disease outbreaks. She points to the capacity of infectious diseases to create fear and anxiety that lead to alterations in human lifestyles and behaviors, and she demonstrates that the threat of disease transmission can lead to stigmatization of infected individuals and their respective religious or ethnic groups, sexual behaviors, and geographic locales.

Wald begins by defining the concept of an “outbreak narrative,” starting with identification of an emerging infection, following it through the networks of transmission, and ending with its containment. She illustrates this definition with several examples beginning with the story of “superspreader” (Wald’s term) Mary Mallon—also known as Typhoid Mary—who was among the first human typhoid carriers to be identified.

Typhoid is transmitted by ingesting food or water contaminated during handling by a human carrier (usually an asymptomatic individual who has survived the illness but continues to excrete infectious bacteria in the stool). While working as a cook in several New York City households in the early 1900s, Mary Mallon infected dozens of individuals; many died. In that period the concept that a person could remain healthy yet spread disease was not widely understood or accepted. Mallon’s fame is due to her vehement denial of her own role in causing disease, together with her refusal to cease working as a cook. She was forcibly quarantined twice by public health authorities. Sociologic issues of the era, including notions about gender roles and prejudice against working-class Irish immigrants, may have contributed to her defiance.

Wald asserts that the “outbreak narrative” of this famous public health story illustrates that the responsibility for control of disease transmission must be shared by all members of society. As she writes, “cleanliness became not only a solution but a measure of citizenship.” She goes on to say that stigmatization of individuals or groups must be overcome to create the culture of hygienic responsibility among individuals and in the community that is critical for prevention of disease.

The book is intended for a scholarly audience and thoroughly reviews various sources, including historical accounts, media reports, literary sources, and film. Wald appropriately cites others who have articulated similar themes, including William H. McNeill’s Plagues and Peoples (1977), Paul Farmer’s Infections and Inequalities (1999), and Jared Diamond’s Guns, Germs and Steel (1997).

Wald is hopeful that “an analysis of how the . . . outbreak narrative shape[s] attitudes toward disease emergence and social transformation can lead to more effective, just, and compassionate responses to the problems of global health and human welfare.” In our increasingly interconnected world, the outbreak narratives we write as we respond to modern-day plagues will likely define the course of human civilization.

As Wald has illustrated, for the optimal outbreak narrative, every member of society must play a critical part. Public health officials and epidemiologists must perform active surveillance for emerging infections. Scientists must study the nature of infectious pathogens to develop methods for treatment and prevention. Government leaders must recognize the increasingly important role that pathogens play in the modern era and prioritize the funds and policies required for proper investigation and control. Journalists must communicate honestly and rationally about communicable diseases to the public, so as to engender a sense of individual responsibility without creating undue fear leading to irrational...