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One recurring theme of the previous chapter was the role of military assembly and training camps as sites for explosive outbreaks of infectious diseases during periods of wartime mobilization. Historically, however, the general problem of camp epidemics has extended beyond the initial massing of unseasoned recruits in barrack and tent camps on home soil to include the field camps, siege camps, and bivouacs of deployed armies, as well as temporary and makeshift military settlements such as prisoner of war (POW) and concentration camps. In this chapter, we examine the broader issue of camp epidemics (Theme 2 in Table III.A) with reference to sample wars in the European theatre. The social, physical, and environmental conditions that fuelled the spread of diseases in the military encampments of past wars, and which remain a potent threat in modern conflicts, are well known (Prinzing, 1916; Major, 1940; Bayne-Jones, 1968; Cantlie, 1974; Shepherd, 1991). As illustrated in Chapter 7 by the mobilization camps of the United States, military encampments of all kinds—often hastily erected and densely populated—provide a setting for intense population mixing, thereby increasing the likelihood of the transmission of infectious diseases. The epidemiological hazard is exacerbated by the injudicious selection of campsites and by the deleterious consequences of overcrowding, inadequate or non-existent drainage and sewerage systems, poor or contaminated water supplies, and by the failure to institute or to maintain rigid sanitary precautions. As for the occupants, they may be drawn from a variety of epidemiological backgrounds, they may possess different patterns of disease immunity, and their resistance to infection may be compromised by fatigue, trauma, mental and physical stress, exposure to the elements, and poor or inadequate diets. That there is often a high degree of spatial mobility between the constituent units of a camp system adds a powerful geographical component to the spread of camp epidemics. Against this background, the case studies presented in this chapter have been selected to illustrate different aspects of the geographical spread of camp epidemics.

Disease is a head of the Hydra, War. In his classic book, The Epidemics of the Middle Ages, J. F. C. Hecker (1859) paints an apocalyptic picture of the war–disease association. For Hecker, infectious diseases, the ‘unfettered powers of nature . . . inscrutable in their dominion, destructive in their effects, stay the course of events, baffle the grandest plans, paralyse the boldest flights of the mind, and when victory seemed within their grasp, have often annihilated embattled hosts with the flaming sword of the angel of death’ (Hecker, 1859: 212). The theme is developed by August Hirsch who, in the second edition of his Handbook of Geographical and Historical Pathology (1883), was repeatedly moved to comment on the manner in which wars fuelled the spread of infectious diseases. Writing of Asiatic cholera in the Baltic provinces and Poland in 1830–1, Hirsch concluded that the ‘military operations of the Russo-Polish war contributed materially to its diffusion’ (i. 398). Similarly, Hirsch traced one of the last ‘considerable’ outbreaks of bubonic plague in nineteenth-century Europe to ‘1828–29, when the Russian and Turkish forces came into collision in Wallachia’ (i. 503–4), while the waves of typhus fever that rolled around early-modern Europe were attributed to ‘the turmoil of great wars, which . . . shook the whole framework of European society to its foundations’ (i. 549). In much earlier times, Book I of Homer’s epic poem the Iliad—which may well be based on historical fact—tells of a mysterious epidemic that smote the camp of the Greek Army outside Troy around 1200 BC. According to Homer, the fate of King Agamemnon’s legions was sealed thus: . . . Say then, what God the fatal strife provoked? Jove’s and Latona’s son; he filled with wrath Against the King, with deadly pestilence The camp afflicted,—and the people died,— For Chryses’ sake . . . . . . Elsewhere, the celebrated works of ancient Greek historians—Herodotus (?484–?425 BC) on the later Assyrian Wars, Thucydides (?460–?395 BC) on the Great Peloponnesian War and Diodorus Siculus ( fl. first century BC) on the Carthaginian Wars—all attest to the antiquity of the war–disease association. Of ancient Rome, Bruce-Chwatt notes that ‘Foreign invaders . . . found that the deadly fevers of the Compagna Romana protected the Eternal City better than any man-made weapons’ (cited in Beadle and Hoffman, 1993: 320).

So far, the geographical foci of our regional–thematic examination of the linkages between war and disease have been the great continental land masses of the Americas, Europe, Asia, and Africa. We now turn our attention to a different stage for the geographical spread of war epidemics—oceanic islands. As well as the particular interest which attaches to islands as natural laboratories for the study of epidemiological processes (Cliff et al., 1981, 2000), island epidemics also hold a special place in war history. For example, we saw in Chapter 2 how the islands of the Caribbean became staging posts for the spread of wave upon wave of Old World ‘eruptive fevers’ (especially measles, plague, smallpox, and typhus) brought by the Spanish conquistadores to the Americas during the sixteenth century. Much later, the mysterious fever that broke out on the island of Walcheren in 1809 ranks as one of the greatest medical disasters to have befallen the British Army. In this chapter, we examine the theme of island epidemics with special reference to the military engagements of Australia, New Zealand, and the neighbouring islands of the South Pacific since 1850. Figure 11.1 serves as a location map for the discussion, while sample conflicts—exclusive of tribal feuds, skirmishes, and other minor events for which little or no documentary evidence exists—are listed in Table 11.1. Our analysis begins in Section 11.2. There we provide a brief review of the initial introduction and spread of some of the Old World diseases which occurred in association with South Pacific colonization and conflicts during the last half of the nineteenth century. In Sections 11.3 and 11.4, we move on to the twentieth century. In the Great War, Australia and New Zealand made a relatively larger contribution to military manpower than any other allied country. At the end of the conflict, the return of many tens of thousands of antipodean troops from the battlefields of Europe fuelled the extension of the 1918–19 ‘Spanish’ influenza pandemic into the South Pacific region (Cumpston, 1919). In Section 11.3, we examine the spread of influenza on board returning troopships and subsequently within Australia, New Zealand, and the neighbouring islands of the region.

This chapter addresses failures in healthcare (AIDS and Opioids Epidemics), the economy (Great Depression and Recession), and the environment (Population and Climate). Multi-level analyses are used to provide comparisons across case studies. How these types of domains anticipate and manage failures are briefly reviewed. Surveilling versus controlling failures are contrasted. These insights are used to foreshadow later discussions of failure management.

This concluding chapter looks at the Robert Wood Johnson Foundation’s (RWJF) renewed resolve to highlight connections, rather than differences, when it talks about common problems, and to take evidence-based action grounded in that shared understanding. Despite an abundance of political rhetoric, this book has shown that there is ample enthusiasm for doing just that. A cross-sectional movement to address climate change is on the rise, bringing together businesses, hospitals, and activists. The opioid epidemic and its intersections with rural health and mass incarceration are gaining attention across partisan divides. Medical systems are integrating the social determinants of health into their care interventions, and novel payer initiatives are making it feasible to pilot test and evaluate innovation. Resilience also has come to the forefront as people learn more about the risks associated with childhood trauma, weather-related and human-spawned disasters, and community fragmentation, as well as the protective factors that can counter those stressors and foster personal and collective renewal. Ultimately, the pursuit of health equity remains the underpinning of everything the RWJF does. As they explore further the cultural aspect of a Culture of Health, they are bolstering their commitment to empower historically marginalized people.

We now know that anthropogenic emissions of greenhouse gases (GHGs) are interfering with the planet’s climate system in ways that are likely to lead to dangerous threats to human life (not to mention nonhuman life) and that are likely to compromise the fundamental well-being of people who live at a later time. We have not understood this for very long—for most of my life, for example, we were basically clueless about climate. Our recently acquired knowledge means that decisions about climate policy are no longer properly understood as decisions entirely about preferences of ours but also crucially about the vulnerabilities of others—not about the question “How much would we like to spend to slow climate change?” but about “How little are we in decency permitted to spend in light of the difficulties and the risks of difficulties to which we are likely otherwise to expose people, people already living and people yet to live?” For we now realize that the carbon-centered energy regime under which we live is modifying the human habitat, creating a more dangerous world for the living and for posterity. Our technologically primitive energy regime based on setting fire to fossil fuels is storing up, in the planet’s radically altering atmosphere, sources of added threat for people who are vulnerable to us and cannot protect themselves against the consequences of our decisions for the circumstances in which they will have to live—most notably, whichever people inherit the worn-and-torn planet we vacate. As we academics love to note, matters are, of course, complicated. Let’s look at a few of the complications, concentrating on some concerning risk. Mostly, we are talking about risks because, although we know strikingly much more about the planetary climate system than we did a generation ago, much is still unknown and unpredictable. I will offer three comments about risk. The third comment is the crucial one and makes a strong claim about a specific type of risk, with three distinctive features.

The first draft of this chapter was written before the pandemic alert for the 2009 flu was launched. Since then, terms such as swine flu, Mexican flu, or H1N1 were constantly in the headlines. We witnessed the first really worldwide outbreak of a new influenza strain. Events went faster than we foresaw in our original text. We had started the chapter with an imaginary scenario of an outbreak in 2013 not in Mexico but in the East Java, Indonesia, city of Malang. It was not really meant as a prediction but merely a little story to show the consequences of an outbreak. We wanted to show how disruptive the outbreak of a new disease might be. We described all the things that we are now familiar with: doctors who aren’t particularly worried in the beginning; people that live close to their animals and pick up viruses; patients in hospitals with high fever and severe cough; pharmaceutical companies anxious to peddle expensive vaccines. Then we invented some struggle between the Indonesian authorities and the World Health Organization (WHO) about blood samples. That reflects the reluctance of developing nations to cooperate in the production of vaccines they can never afford. In our story, the rest of the world ignored this imaginary outbreak and was oblivious to the rising death toll and the diplomatic wrangling. That’s just like the start of the 2009 flu that probably haunted Mexican villages for many weeks unreported. In our story, the silence was broken when two nurses died in Perth, Australia. The media seized on the story immediately with yelling headlines. In the week that followed, dozens of new cases were reported in Indonesia, Australia, and Singapore, together with the first suspected case in New York. Then there follows all the health humdrum that we are now so familiar with. The WHO has got hold of the flu virus and is preparing to produce a new vaccine. However, the epidemic spreads like an oil slick with the virus striking one major city after another. Antivirals change hands over the Internet for huge sums despite doctors’ warnings that the drugs only work if administered within a few hours of infection.

Host–pathogen associations continue to generate some of the most important applied problems in population biology. In addition, as foreshadowed in Chapter 5 of this volume, these systems give important insights into the dynamics of host– natural enemy interactions in general. The special place of pathogens in the study of host–natural enemy dynamics arises partly from excellent longterm disease-incidence data, reflecting the public health importance of many infections. However, we argue that host–pathogen dynamics are also distinctive because the intimate association between individual hosts and their pathogens is often reflected with particular clarity in the associated population dynamics. Throughout this chapter we focus in parallel on the population dynamics of host–pathogen interactions and the insights that host–pathogen dynamics can provide for population biology in general. Population-dynamic studies of infectious disease have a long history, which predates the modern foundations of ecology (Bernoulli, 1760). During the twentieth century, the preoccupation of population ecologists with the balance between extrinsic and intrinsic influences on population fluctuations and the role of nonlinearity and heterogeneity (Bjørnstad and Grenfell, 2001) find strong parallels in epidemiological studies of human diseases (Bartlett, 1956; Anderson and May, 1991). In terms of the ecological effects of parasitism, the traditional view held that ‘welladapted’ parasites would not have a consistent impact on the ecology of their hosts (Grenfell and Dobson, 1995). The 1970s saw a new departure, when Anderson and May pointed out the potential of infectious agents to exert nonlinear—regulatory or destabilizing—influences on the population dynamics of their hosts (Anderson and May, 1978, 1979; May and Anderson, 1978, 1979). There has since been an explosion of work on the population biology of human, animal, and plant pathogens. This work spans a huge range: from highly applied to basic theoretical work; from within-host to the metapopulation scale; from short-term population dynamics to long-term evolutionary processes. In this chapter we first outline the simple theory of epidemiological models; we then refine this picture to illustrate the potential impact of pathogens on the population dynamics of their hosts, as well as aspects of host–pathogen interactions which provide important insights into more general ecological dynamics.

To Return To The Bulk of our material in this book, what absolute differences separate the United States from Europe? The United States is a nation where proportionately more people are murdered each year, more are jailed, and more own guns than anywhere in Europe. The death penalty is still law. Religious belief is more fervent and widespread. A smaller percentage of citizens vote. Collective bargaining covers relatively fewer workers, and the state’s tax take is lower. Inequality is somewhat more pronounced. That is about it. In almost every other respect, differences are ones of degree, rather than kind. Oft en, they do not exist, or if they do, no more so than the same disparities hold true within Western Europe itself. At the very least, this suggests that farreaching claims to radical differences across the Atlantic have been overstated. Even on violence—a salient difference that leaps unprompted from the evidence, both statistical and anecdotal—the contrast depends on how it is framed. Without question, murder rates are dramatically different across the Atlantic. And, of course, murder is the most shocking form of sudden, unexpected death, unsettling communities, leaving survivors bereaved and mourning. But consider a wider definition of unanticipated, immediate, and profoundly disrupting death. Suicide is oft en thought of as the exit option for old, sick men anticipating the inevitable, and therefore not something that changes the world around them. But, in fact, the distribution of suicide over the lifespan is broadly uniform. In Iceland, Ireland, the UK, and the United States, more young men (below forty-five) than old do themselves in. In Finland, Luxembourg, the Netherlands, and Norway, the figures are almost equal. Elsewhere, the older have a slight edge. But overall, the ratio between young and old suicides approximates 1:1. Broadly speaking, and sticking with the sex that most oft en kills itself, men do away with themselves as oft en when they are younger and possibly still husbands, fathers, and sons as they do when they are older and when their actions are perhaps fraught with less consequence for others. Suicide is as unsettling, and oft en even more so, for survivors as murder.

This chapter is about pandemics, a somewhat ambiguous term, defined in the Oxford English Dictionary as ‘a disease prevalent throughout a country, a continent, or the world’. In present modern usage the term takes greater cognizance of its original Greek derivation and is largely restricted to global prevalence (pan demos) – all people. The same source tells us that ‘plague’ has a broader meaning, implying a sudden unexpected event that is not necessarily a disease, but introducing the concept of acute, lethal, and sudden danger – characteristics that are connoted but not specifically denoted by the term ‘pandemic’. It will become apparent that glimpses of the future must consider the emergence of new pathogens, the re-emergence of old ones, the anthropogenic fabrication of novel agents, and changes in the environment and in human behaviour. In other words ‘the problem’ in addressing infectious disease threats is not one but many separable problems, each of which must be isolated in traditional scientific fashion and separately evaluated as components of what I like to call ‘holistic epidemiology’. This emerging discipline comprises microbial and human genetics, human behaviour, global ecology, toxicology, and environmental change. As we leave our mothers’ wombs and enter this vale of tears (and sometimes before) we are invaded by microbes that may become our lifelong companions, profiting from this intimate relationship by the food and shelter that our bodies offer. They, in turn, often provide us with nutrients or vitamins derived from their own metabolic processes and may even immunize us against future assaults by related but less kindly microbes. In other words, we and they (usually) coexist in a state of armed neutrality and equilibrium. But humans bear a chronic burden of infectious diseases. Included in this burden are some diseases that have demonstrated a capacity to break out in pandemic form, depending on the circumstances that are defined later. The less overt contributors to human misery will be briefly reviewed before discussing the nature of the acute aberrations that comprise the more dramatic pandemics and plagues that suddenly burst forth in a catastrophic manner.

A network of east central European health experts involved in the state-building of their post-imperial region were responsible for the methods and objectives of the League of Nations Health Organization. Their programmes challenged both western influence in public health and the great powers’ dominance within interwar internationalism. The health services of east central Europe did not evolve in national isolation, and their principles of mutual assistance became the basis for the League Health Organization to redefine human security and to support early international development projects.

This chapter addresses the unprecedented public health crisis of opioid addiction and deaths by overdose. The opioid epidemic demonstrates just how far many regions are from achieving a Culture of Health. Advancing health equity requires addressing the multifaceted drivers of the opioid epidemic through innovative multisector programs that shift the emphasis from punishment and stigma to upstream solutions. Driven by an understanding of the unique cultural and historical contexts of their communities, front-line advocates and policymakers at all levels will need to collaborate on a package of well-coordinated strategies. The chapter then looks at states that are targeting both the supply of opioids and the demand for them with creative “whole community” approaches, shifting away from the criminal justice system, providing better access to treatment, and crafting innovative reimbursement strategies.

This chapter explores the practice of collecting cancer statistics and examines the meanings and implications of the nascent idea of the ‘cancer epidemic’ in the mid-nineteenth century. In response to the supposed increasing incidence of cancer, some medical men sought strategies beyond the clinic to elucidate the evasive malady. The continued therapeutic futility with respect to cancer provoked a diversification of investigative efforts, and elements of the medical community refocused on the disease’s causes, prevention, transmission, and potential communication. This chapter explores the ways in which practitioners interested in cancer—little-known characters like Alfred Haviland, Charles H. Moore, and Charles E. Green—mapped cancer incidence, understood the disease to be produced by rural environs, and conceptualized the disease spatially and according to scale.

This chapter analyses and assesses the medical practitioners and social commentators who searched for an explanation for the new ‘cancer epidemic’ in Victorian Britain. While Chapters 5 and 6 looked at medical men who, using a range of techniques and technologies, attempted to decode the aetiology of cancer and explain and arrest its expansion, the limited success of these efforts prompted some observers to suggest that perhaps the origin of malignancy could be found in the very fabric of modern society. If it was not latent in the landscape, nor a waxing and waning infectious disease, then maybe cancer’s increasing incidence was a sign of some change in the bodies and lifestyles of the nation and its inhabitants.

This chapter focuses on the concept of “governing through contagion.” Flexing power over life, governing through contagion regulates subjects of a population to ensure their bodies are free from contagion, do not spread contagion to fellow subjects, and stay economically productive—or at least, avoid incurring economic costs of medicine and containment. In many territories, the legal strategies of control in response to the Covid-19 pandemic, such as quarantine orders and movement restrictions, grew out of earlier episodes of contagion that significantly shaped governing through contagion. The chapter then introduces three themes of governing through contagion: centralization and technology of law; normalization and technologies of moralization; and inter/dysconnectedness and the rearticulation of difference. The analysis draws on the historical ethnography of one British post-colony, Singapore, situated in three contexts: the colonial era (particularly 1868–1915), which was troubled by numerous epidemics such as plague, cholera, and smallpox; the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak; and the Covid-19 pandemic.

This chapter discusses the shortcomings of the current global health regime and proposes a new framework based on Woodrow Wilson’s ideas about global interaction and responsibility. The authors explain how critical it is to establish a successful new system, given climate change, microbial evolution, and the current political landscape. The proposed system must resolve the tension between national sovereignty and national interdependence, while also improving response time and investing in long-term solutions. The authors conclude that these guidelines can be met by introducing engaged pluralism and ambidextrous leadership.

In the 1920s, Polish state officials saw the newly established and poorly guarded Polish-Soviet border as a site of both anxiety and opportunity. As refugees and remigrants from the First World War and subsequent borderland conflicts moved westward, politicians raised fears about humanitarian crises, epidemic diseases, and anti-Polish ideological infiltration. At a local level, however, border guards and state policemen were more concerned with peasant criminality, including smuggling, horse theft, and illegal distilling, that ran along and across national lines. Since such behavior, when combined with communist agitation, appeared to threaten the state’s territorial sovereignty, the government created a new border guard corps in 1924 to militarize the border and “civilize” local people. But although border guards appeared in Polish propaganda as heroes in a hostile physical and human environment, they feared the effects of daily contact with the Soviet Union—and with civilians on the Polish side.

This chapter discusses how railroads became a vector for the spread of yellow fever in a series of epidemics. It focuses first on a devastating outbreak that spread north from New Orleans in 1878 along rail corridors. As southerners realized that railroads were spreading contagion, and as railroad companies refused to halt or shutdown traffic, conflicts between small towns and railroad companies emerged. The next major outbreak in the region, in 1888 in Jacksonville, witnessed widespread “shotgun quarantines,” in which local vigilantes tied up rail traffic. In 1897, Mississippi citizens reacted to an outbreak with violence against railroad infrastructure. Federal and state health officials tried to create boards of health and institute rational quarantine policies but their ultimate failure to control shotgun quarantines reflected a lack of trust in railroad companies and regional anxieties over new railroad connections and circulation. Yellow fever scares like this continued until Walter Reed’s discovery that the mosquito transmitted the disease and the last major outbreak in the region was in 1905.