September 13th, 2010

_Inside the Outbreaks_, Mark Pendergrast

Subtitled: the Elite Medical Detectives of the Epidemic Intelligence Service

The reviews on Amazon for this book are all over the place. I picked this up at a bookshop in Concord (I know! I didn't buy it on the kindle! Shocking!), in part because I remembered reading Pendergrast's book about coffee (_Uncommon Grounds_) and enjoying it in an uncomplicated way. It is not often the case that I read a book and have No Issues, but Pendergrast seems to work for me.

Pendergrast means that subtitle, whether he had anything to do with it or not. This is not precisely the story of the EIS, much less the CDC or any other fraction of the massive public health bureaucracy here or elsewhere in the world. It really is the story of a whole series of men and women who were sent places in the US and abroad to try to figure out why people were getting sick, hurt and/or dying with the goal of then applying that knowledge to determine an appropriate intervention to prevent or mitigate the getting sick, hurt and/or dying and communicate it clearly to people who might then implement it. Ideally quickly.

Obviously, you can't tell the story of these men and women without mentioning the organization(s) they belong to and are helped and hindered by and the other people in those organizations. But it isn't the story of the organizations, so there's more a tidbit here and a tidbit there and a few paragraphs about how disruptive Julie Gerberding was (surprise), rather than a comprehensive and organized presentation of how the budget is structured and how that changed over time and all the modifications to the organization and so on and so forth.

If you've read things like Preston's _Hot Zone_ or Laurie Garrett's _The Coming Plague_ and are expecting the same kind of DOOMy nailbiter (or, heck, even Regis' _The Biology of Doom_), Pendergrast does not deliver. Preston vividly places you in the middle of a (possible) plague. Garrett inundates her reader with myriads of possible ways we're all going to die, some day, when something mutates, or we invade the wrong last bit of habitat and eat the wrong something-or-other or accidentally get poked by a needle infected with something or whatever. Regis has a bit too much of a sense of humor and sense of perspective to really go at it, but his topic is so incredibly depressing (because what comes our way without assistance isn't bad enough, no, the military-industrial complex has to try to go one better. Of course, the good news here is that they aren't any worse than anything that happens randomly. So far. Cue doomy music.) it has a twisted power all its own.

_Inside the Outbreaks_ is in some ways closer to Pisani's never-to-be-sufficiently-recommended _Wisdom of Whores_. Yep, there's some awful stuff out there, making people sick or hurt and/or killing them. Yep, some of that stuff can be slowed down or even stopped, but it costs a lot of money, either to cure individuals or to prevent on a large scale, and worse, even when you have the resources, deploying those resources can be next to impossible, because of intractable things like warfare, lack of a functioning state, random rumor and misinformation, religious or cultural beliefs...

But you can make progress, especially if you get some energetic people out there, and they work _with_ locals and successful improvisations get repeated and communicated, and you measure efficacy and the effective stuff is repeated and the ineffective stuff gets ditched and, most importantly, you try really hard not to _lie_ about how effective you are being when you aren't being effective at all (that being what did in the malaria eradication attempts which preceded the smallpox eradication attempts, which almost didn't get funded because of all the lying that went on with the DDT spraying).

In much the same way that Pisani keeps coming back to some very, very, very simple things that turn out to be wicked hard to make happen (Use condoms. Every time. Reduce the number of partners you have. Don't share needles. Ever. Fund programs that distribute condoms and needles, even if you don't much care for the people you are keeping alive, because people you _do_ care about may be having intimate contact with those people who will otherwise share needles and not use condoms and then they'll die, too. Also, it is the Right Thing to Do.), Pendergrast keeps coming back to the basics: Clean Water. Clean food. Physical security (whether from bombs or people who might steal your food or from mosquitos). Surveillance of disease. Oh, and a well-maintained cold chain where necessary. Yeah, okay, a whole lot of stuff about cross-contamination, and an occasional story about something weird and rare that only pops up under unusual circumstances but boy howdy when those circumstances happen it gets ugly.

Pisani and Pendergrast are telling the mechanical stories of how humans and disease interact. Pendergrast is still caught up in the whole find-bug-kill-it mindset of a lot of epidemiologists, which is the only complaint I have about this book -- there's no nuance whatsoever to his discussion of group B strep in pregnant women and what to do about it, and he's pretty clear about where his sympathies lay with the early rotavirus vaccine that was removed from the market. But that mechanical story is an incredibly important story (hey, I'm aspie enough to think it's really the _only_ story to be told, but I know other people feel differently), even if it is awful messy at times.

Should you read it? You might learn something, and I don't think it would do you any harm to speak of. But if you buy it because of that fantastic cover with the cartoon design you are probably going to be a little let down by what this book isn't, even while you're busy improving your mind with what this book is.

And that whole thing with the rabid bat saliva that it didn't even occur to early EIS guys to worry about? Emblematic of the Not Thinking Clearly that explains so much of the mid 20th century.