The black death daily paragraph editing

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Table of Contents

Title Page

Dedication Introduction INTRODUCTION CHAPTER 1 - THE SENSE OF AN EPIDEMIC CHAPTER 2 - PLAGUE: BIRTH OF THE MODEL EPIDEMIC

THE COMING OF PLAGUE TO EUROPE DISEASE AND FEARS OF CONSPIRACY PLAGUE AND VIOLENCE TOWARD JEWS ILLNESS AND FAITH PLAGUE AND THE GROWTH OF THE STATE “BLACK DEATH”

CHAPTER 3 - CHOLERA, POVERTY, AND THE POLITICIZED EPIDEMIC

CHOLERA’S BEGINNINGS A DISEASE OF THE POOR THE POLITICAL TRANSFORMATION OF ILLNESS MIASMA AND THE RISE OF SCIENCE CHOLERA AND UTILITARIANISM CHOLERA IN AMERICA ILLNESS AND IMMIGRATION

CHAPTER 4 - GERMS, SCIENCE, AND THE STRANGER

GERM THEORY VICTORIOUS THE BIRTH AND GROWTH OF EPIDEMIOLOGY MICROBIOLOGY’S DEBUT EVOLUTION, SOCIAL DARWINISM, AND THE CARRIER GERMS IN AMERICA GERMS, FLU, AND FEAR THE AFTERMATH OF GERM THEORY

CHAPTER 5 - THE CONQUEST OF CONTAGION

PROGRESSIVISM AND MORALISM GERMS AND THE SEXUAL REVOLUTION “YOU CANNOT HAVE OMELETTES WITHOUT BREAKING EGGS”

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BEYOND EUGENICS BEYOND GERM THEORY

CHAPTER 6 - POSTMODERN EPIDEMICS

AN EXTRAORDINARY EPIDEMIC DEBATES ABOUT DEVIANCE THE MIXING OF CAUSE AND EFFECT THE BEHAVIORAL TURN: EDUCATION AS POLICY EDUCATION IN LIEU OF POLICY THE PERSISTENT THEME OF BEHAVIOR THE WORLD’S EPIDEMIC

CHAPTER 7 - MANAGING THE IMAGINED EPIDEMIC

THE BIOTERRORISM SCARE HEALTH OFFICIALS AS SOOTHSAYERS THE OBESITY SCARE OBESITY AS FALL GUY FOR MODERN FEARS MANAGING MISGIVINGS ABOUT PARENTING: CHILDHOOD

OBESITY AUTISM, THE ADMINISTRATIVE EPIDEMIC

EPILOGUE

Acknowledgements NOTES SELECTED BIBLIOGRAPHY INDEX Copyright Page

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To my father

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INTRODUCTION TO THE PAPERBACK EDITION

A half-year after the hardcover publication of Dread, sleeves across America were being rolled up for the swine flu vaccine. New York City set out to inoculate schoolchildren, and pregnant women lined up to get vaccinated at their obstetricians’ offices. Although the swine flu outbreak had caused less harm in the six months since it started than almost any flu event of the past century, everyone was alarmed. And everyone had questions.

At a symposium in Holland, people asked me whether I thought their government really needed to buy up enough flu vaccine for every Dutch citizen. A reporter in Chicago told me he saw boycotts of soccer games involving Mexican teams, because people thought the flu could be spread by Mexicans. A Canadian radio host asked whether her country was worrying too much about the flu. An Australian physician and another in France chided me for my refusal to endorse the sky-is-falling rhetoric of flu preparedness. Around the U.S., hand-sanitizer dispensers flowered at supermarket checkouts, airport security points, libraries, and classrooms; colleagues and friends wondered whether the sanitizing gel could really stop the flu virus. At home in New York, nurses cried foul at mandatory immunizations (later rescinded). Physicians expressed frustration at the difficulty of persuading parents to have their kids immunized against flu. Parents everywhere were wary of exposing their child to yet another vaccine, and wondered if they were being sold a bill of goods by health officials. The Boston Globe reported that vaccine manufacturers were expecting to take in $7 billion from swine flu in 2009 alone.

A big threat—or just big hype? In the fall of 2009, no one could ignore the swine flu. It was in the headlines, a feature of television talk shows, the subject of conferences and official press releases, the theme for posters reminding us to wash our hands, the reason why some people donned masks on the subway and others refused to shake hands, the trigger for new policies in schools and colleges and, of course, the billions of taxpayer dollars, euros, and yen spent on vaccines.

Swine flu, or “H1N1 2009,” made the premise of this book seem prophetic. As an epidemiologist and compassionate observer, it’s impossible for me to be happy about a nasty disease outbreak responsible for thousands of deaths. As an author, though, it’s gratifying that the outbreak, and its attendant debates, so quickly proved the book’s point: that a society’s epidemic narrative reflects its own anxieties and dreads—not necessarily real harm or ensuing suffering.

From the beginning, both media and health officials depicted the flu outbreak of 2009 as a crisis. American newsmakers and media in particular had a decided influence on international news.

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The crisis began in April 2009, when brief reports of an unusual flu strain in California and Texas were followed by a summary article in the New York Times that effectively set the stage for pandemic worry. The first major news coverage, the Times’s article “Unusual Strain of Swine Flu Is Found in People in 2 States,” made several points that were crucial to shaping the pandemic narrative. The article hinted that a new strain of flu was afoot, that it came from Mexico, and that it had some of the characteristics of past pandemic strains. Although no link had been established between seven cases of flu in California and Texas and an outbreak of adult respiratory illness in Mexico, the article reported that Mexican authorities had noted a high death rate there—essentially creating an association in people’s minds. It reported that the new flu was made up of genetic elements “from North American swine, bird, and human flu strains as well as one from Eurasian swine.” And it pointed out that all the new cases were under the age of 55, lower than the usual age range for serious flu cases.

The next day’s Times story, “Fighting Deadly Flu, Mexico Shuts Schools,” explicitly linked the Mexican outbreak to the disastrous flu outbreak of 1918, which killed tens of millions of people worldwide in a matter of months. Measured in deaths per month, the Spanish Flu has never been equaled. When the Times piece pointed out that the young age of the 2009 flu victims was worrisome because “pandemic flus—like the 1918 Spanish Flu . . .—often strike young, healthy people the hardest,” alarm bells went off.

In the first two days of reporting, America’s premier newspaper had established the grammar for the story of a new pandemic: There was a new strain of influenza. It came from animals. It was causing a big outbreak in a country that, significantly for Americans, is not only poor but has long been suspected of exporting noxious influences northward—including drugs, the Spanish language, and undocumented immigrants. Its pathologic pattern was similar to that of the 1918 flu (and so was its origin in animals). As in 1918, schools were being closed. The story of global threat was being written, and read, widely.

As is so often true, the epidemic is a story of crisis. And a pandemic becomes a pandemic as the crisis story is recounted by the media. The New York Times’s flu coverage jumped in 2003. That year, the paper ran fifty articles on flu, mostly focusing on the threat posed by H5N1, the avian flu. In the following year, while the government in Washington shifted from bioterrorism preparedness to flu- pandemic preparedness (the White House had kicked off the bioterrorism preparedness fad with Project Bioshield in 2002, but issued a new pandemic plan focusing on flu in August 2004), flu coverage in the Times climbed to over ninety articles per year, where it remained for some time. The Washington Post showed a similar pattern, with flu coverage nearly tripling between 2002 and 2004 and continuing to rise thereafter. A Times reader would have encountered an article on flu roughly every six weeks before 1996; by 2006 she would see one every four days. A Post reader would have seen flu mentioned in the paper’s A section about once a week in 2002, but nearly once per day by 2006.

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But don’t blame the news media alone. They package the news on diseases as it is created by health officials, scientists, funding agencies, regulatory agencies, and others. It’s better to look at the account of swine-flu-as-global-threat as the Preparedness Crusade—a rhetorical campaign launched by a virtual industry whose product is health threats. Public health officials, agencies and foundations that provide monies for research, scientific and health researchers, industries that make products supposedly designed to protect against threats, and, yes, the media, all benefit when the public is alarmed.

For government agencies, an aim of the preparedness rhetoric has been to play on people’s ingrained sense of vulnerability in the modern world, and on putatively highlighted fears after the September 11 disasters. But this unease hardly began in 2001; it is a most unmodern feeling that can be traced back at least to the Middle Ages. It is the very reason why Christians of the Black Death era thought God had sent plague to punish impiousness, and why when cholera arrived in 1848 Americans held a national fast day to expiate what many saw as the faithless imprudence of a restless nation. The worry that our social arrangements invite disaster in ways that our forebears’ social arrangements did not—the sense that the good old days were safer and happier—always crystallizes when there is a threat of epidemic illness. We suspect we are receiving our just deserts. Those who want our affection, our dollars, or our votes have always been able to capitalize on that anxiety. The preparedness rhetoric, as promoted by the White House but endorsed by the industries of public health and medicine in America and, increasingly, abroad, evokes a frightening future. It asserts that only scientists and health officials can read its auguries correctly. And it demands that the public allow officials to state what is going to go wrong and what must be done to prevent that.

Forecasting a frightening future that’s manageable only by state officials is not purely an American habit. Although it was the director of the U.S. Centers for Disease Control and Prevention who forthrightly called swine flu “a major problem [that] requires a major response,” he was not alone. The Chinese government invoked special authority to restrict liberties in the name of staving off epidemics—and used it to quarantine foreigners visiting the country. British officials were criticized for failing to force widespread flu testing, and the U.K. health minister responded with an incautious (and fantastical) forecast of 100,000 new cases per day. Russia officially banned pork imports from the U.S. And Egypt’s regime set out to kill 300,000 pigs.

In early June 2009, the World Health Organization declared swine flu a pandemic. Dire scenarios involving widespread death and economic duress were predicted. In August, a White House scientific advisory committee predicted that flu might infect a third to a half of all Americans—up to 150 million people, that is —and lead to as many as 1.8 million hospitalizations and 90,000 deaths. Committee members defended their inclusion of such a horror scenario in their supposedly scientific report, claiming they were not predicting but merely attempting to examine scientifically the plausible upper edge of possible outcomes

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of the outbreak. But were they really shocked when the news media seized on their “scenario” as a certainty and broadcast the news that the president’s science advisors thought swine flu would kill 90,000 Americans?

The dire forecasts were useful to some people, though. Opinion makers and moral entrepreneurs had been issuing sky-is-falling warnings about flu for years, part of the new American industry devoted to creating health scares. Now, health professionals pointed to the new flu forecasts as if the mere suspicion of mass hospitalization and death—the “scenario” alone—verified the earlier predictions. For the business of health scare manufacturing, even a mild outbreak of flu can be engineered into the apparent fulfillment of wild expectations.

The expectations came from the preparedness campaign, much promoted by the World Health Organization and supported by statute in the U.S. The preparedness campaign insisted that a cataclysmic global influenza outbreak was bound to happen. It is comforting to think that public policy and planning are based on the observed facts of a disease—incidence, mortality, vaccine efficacy, rate of spread, and so forth. But with flu, expectations of future harm, not facts, drive the discussion. It is as if, once a future has been forecast, it is real and should be treated as real or, as many like to say, “scientific.” The facts of infection rate, vaccine effectiveness, and so forth, appear to validate the forecast—except when the facts debunk the forecast and de-claw the threat, in which case they’re ignored.

As of the end of 2009, about 12,000 people had died from confirmed swine flu infection worldwide. Even accounting for up to 36,000 additional deaths from other causes triggered by swine flu, the 2009 flu killed fewer people in the eight months after the outbreak began than diarrheal illnesses do in the world’s poor countries in any single month. Malaria, TB, and AIDS are likewise far deadlier than swine flu: together they are responsible for 5 million deaths a year, almost all of them in impoverished nations. Swine flu’s toll in 2009 was 100 times less.

But the clemency of flu by comparison to diarrhea, malaria, TB, or AIDS was not a fact deemed relevant in the response to swine flu. Nor was the fact that, in clinical trials, the best flu vaccines protect only about 70 percent of recipients against infection with influenza virus. Or that of the 147 children who died of flu in the U.S. between September ’08 and September ’09, 70 percent also had bacterial infections—suggesting that the problem might not have been flu per se but a failure of medical care to offer appropriate antibiotic treatment to those with severe cases of flu. The fact that antiviral medications like oseltamivir (Tamiflu) have never been shown to reduce the spread of influenza virus was not part of the discussion about distributing the drug; nor was the fact that the U.S. president had successfully pressed for authorization to purchase $1.7 billion worth of Tamiflu in 2005, or that the man who was U.S. secretary of defense at the time had held stock in a company (Gilead Sciences, which had held the original oseltamivir patent) that profited from Tamiflu sales, or that the appearance of swine flu in 2009 upped the purchase of Tamiflu worldwide to 200 million doses, representing additional profit

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for manufacturer Roche. The facts deemed relevant were the ones that supported the preparedness campaign and its parent industry, the one that creates health scares. As this book explains, this pattern is now common with health officials: calling an event an epidemic frees them from the burden of producing facts.

Only a short time after the swine flu outbreak, debate arose over the appropriation of the terms “epidemic” and “pandemic.” On June 11, 2009, the World Health Organization raised its so-called pandemic threat indicator to 6, the highest possible level. “Pandemic,” concocted out of “epidemic,” indicated an outbreak that affects the whole world, and WHO meant it that way. But the agency took flak from public health professionals who decried the delay in declaring a pandemic. At the same time, the agency was attacked by other health professionals who feared that WHO’s proposal that an outbreak’s severity (and not just its extent) should determine whether it was a global threat would dilute what they thought (erroneously) to be the purely scientific meaning of the term pandemic. Another group of commentators criticized WHO for creating such a hubbub over an outbreak that, after three months, was responsible for fewer deaths worldwide than occur in a single weekend on roads in the EU countries.

The debate over whether swine flu should be considered a pandemic, and the more circumscribed debates over whether schools should be closed, travel delayed, Tamiflu stockpiled, etcetera, tended to obscure some of the more compelling questions about flu and epidemics in general.

How much does the sense that swine flu is a global threat stem from its initial recognition in America, for instance? If there had been no flu fatalities in the U.S., would there have been so much demand for a “response” to this pandemic threat? What makes news in the United States, especially when the news is conveyed by the New York Times, Washington Post, or a few other core sources, is especially likely to be carried in non-U.S. news media.

Would people have demanded that WHO raise its pandemic threat barometer to the highest level if their sense of foreboding had not been whetted by years of the pandemic preparedness campaign, with its high price, high profile, and repeated reminders of the horrors of the 1918 flu? When the alleged bioterrorism threat turned out to be chimerical, the preparedness campaign that had manipulated America’s public into supporting endless war shifted to flu. That gave it a more global appeal. But it was still based on the idea of security. How would people have responded to the flu problem if public health, rather than preparedness, had been our watchword? Might we have decided that swine flu was a lesser concern than, say, automobile fatalities—a source of unremitting harm (over 30,000 Americans die in vehicle accidents each year, far more than swine flu claimed in 2009), which, unlike influenza, could really be abated permanently with public policy adjustments regarding public transportation, gasoline prices, urban planning, food industry regulation, and so on? Might we have decided that other

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global problems that don’t affect our own society as much—childhood diarrhea, malaria, or AIDS, for instance—really deserved more attention than swine flu?

Had there been no campaign to create flu fears, this mild outbreak surely would have carried less meaning. But “epidemic” is a loaded term. The discussions about an epidemic—and there have been many, with swine flu—are not really about the facts of illness or death; they are about the competition to impart meaning and convince others that one preferred meaning is correct.

In that sense, the swine flu experience brings to life the central message of this book: throughout history, the facts of harm have often been distant from the perceptions of threat, and the struggle to close the gap has given rise to assertions about risk. When we heed warnings about the supposed need to invest in more germ-fighting technology, when we buy the rhetoric that an epidemic illness must be confronted because of its alleged capacity to damage future generations, when we ignore the self-evident distress of others in order to attend to risk in our own people, or when we agree to give up liberties in exchange for protection from risk, we are acting in the modern version of an old drama, a story in which fears and anxieties are transformed into meaning—into the epidemic.

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INTRODUCTION

THE ORIGINS OF DREAD

Death in it self is nothing; but we fear To be we know not what, we know not where.

—JOHN DRYDEN, AURENG-ZEBE (1675)

Epidemics fascinate us. Look at all the ways we offer accounts of epidemics, and

how often. There are thousands of books in print about epidemics. There are histories of epidemics past, like the Black Death of the 1340s, the yellow fever outbreaks of 1793, cholera in the mid-1800s, the Spanish Flu pandemic of 1918, and polio in the mid-twentieth century. There are dozens of books reporting on today’s pandemic, AIDS. There are books about possible future epidemics, like avian flu. There are “what-if ” books about made-up epidemics sparked by bioterrorism. There are textbooks on epidemic malaria, SARS, dengue fever, encephalitis, HIV infection, and more. There are books about present-day epidemics of obesity, celiac disease, macular degeneration, hepatitis C, anxiety, asthma, attention-deficit/ hyperactivity disorder, autism, childhood bipolar disorders, restless-leg syndrome, mind-body disorders, anger, teen sex, inflammation, methamphetamine use, terror on the Internet, absentee and permissive parents, and “affluenza.” There are myriad fictional accounts of epidemics, including Defoe’s Journal of the Plague Year, Camus’s The Plague, Michael Crichton’s The Andromeda Strain, and Myla Goldberg’s Wickett’s Remedy. There are dozens of films (Outbreak, The Seventh Seal, 28 Days Later, Panic in the Streets, and more). The television programs, magazine articles, and Web sites on all aspects of epidemics are simply countless.

Yet amid the outpouring of words and images about epidemics, much remains hazy. There’s no constant, neatly defined thing that we can all agree is an epidemic. Nor do we agree on how to describe one. For Camus, a plague outbreak in an Algerian city reveals what is most human about its residents. In Tony Kushner’s Angels in America, the AIDS epidemic stands as a metaphor for the sickness within American society in the 1980s. An epidemic of a mysterious “leprosy” in Karel Čapek’s 1937 play The White Scourge is a straightforward

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allegory of ideology-driven imperialism. Cholera reflects the fevered erotic state of Aschenbach, the main character of “Death in Venice,” and the epidemic sets the stage for his demise as he yearns for an inaccessible love. These authors were not ignorant of the scientific findings on disease (by the time Mann wrote “Death in Venice,” in 1912, the Vibrio cholerae bacterium, which causes the disease, had been known for decades, and the means by which it is transmitted were well understood). When F. W. Murnau made Nosferatu, the first film version of Bram Stoker’s Dracula story, in 1922, the details of plague epidemics were well known. But Murnau made use of plague as a harrowing visual motif for the deadly havoc wrought by his film’s vampire, Count Orlock. At almost the same time as Murnau was filming the plague-carrying vampire rising out of a rat-infested ship’s hold to spread disease, public-health authorities were using scientific knowledge to curtail real plague epidemics in Paris and Los Angeles.

Perhaps these contrasts represent no more than instances of artistic license. Leave art aside, then. Our own reactions to illness and death reveal similar contrasts. More than 100,000 Americans die every year from unintentional injuries, including about 40,000 fatalities associated with motor-vehicle crashes. American teens and young adults are more likely to die from unintentional injuries than from any other cause; only homicide and suicide come close. Yet we don’t speak about an epidemic of accidents in the United States, beyond the conversation about automobile safety—and even when we do talk about vehicle mishaps, we rarely go beyond drunk driving. By contrast, there are seven- or eightfold fewer deaths from AIDS in the United States (about 14,000 annually). Still, AIDS provides grounds for continuing admonitions about the perils of drugs and sex, as well as discussions about health-care delivery, community awareness, and sex education. Pneumonia and kidney failure are far more common causes of death, and nobody talks about those as public-health crises. What accounts for the mismatch between the human costs of disease and popular rhetoric about epidemics?

One answer is that epidemics create opportunities to convey messages. The Progressive movement of the early 1900s used epidemics as a rationale to further its program of preventing venereal disease by reshaping sexual mores. The U.S. medical establishment leaned on the epidemic message about infantile paralysis— poliomyelitis—to enable it to finance and carry out a national effort to develop a polio vaccine in the mid-twentieth century. Parents of autistic children in Britain and America today put the epidemic of autism to work to demand that vaccines not be used. Pharmaceutical companies raise the specter of epidemic cervical cancer to promote the vaccine against human papillomavirus. The nature of the epidemic message is neither clear nor constant. Often, the message seems to have less to do with the actual disease burden or death toll than political opportunism. Or money.

Sometimes the lesson we are supposed to learn from an epidemic threat is not the result of any realistic assessment of dangers, but of maneuvering by the fastest claimant or most powerful bidder. What message did “epidemic” convey when, in

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2007, a man said to have “XDR” tuberculosis was arrested by federal authorities, removed from the hospital where he was in isolation, and made the subject of a press conference (and lawsuits) in the name of preventing an epidemic of TB— even though he was not infectious? What does “epidemic” signal when the World Health Organization announces that it sees a global threat in the epidemic of obesity—even though most of the people who are considered “overweight” or “obese” are less likely to die than are people who are very thin? What should we understand by “epidemic” when it is a label we can apply equally to the Black Death and restless-leg syndrome?

When officials or entrepreneurs make use of an epidemic threat to create politically or financially useful lessons, they follow a long tradition. Medieval Christians burned Jews in hopes of warding off epidemics of plague; outbreaks of cholera in the mid-nineteenth century were blamed on Irish immigrants in England and America; early-twentieth-century epidemics of plague in San Francisco and Los Angeles were said to be caused by immigrants (Chinese and Mexican, respectively); and venereal disease epidemics have been attributed historically to “loose women.”

A deeper answer to the question about why hype about epidemics doesn’t line up with the scale of damage has to do with fear. We humans dread death. It is only natural that the mass mortality brought by a great plague makes us afraid. And besides our dread of death, we are frightened by the prospect of social disruption. To live in civilized society is to bear a dread that goes beyond the fear of death.

Perhaps this is what we really mean when we call ourselves developed countries: we live in relative comfort for a comparatively long time (some more comfortably and longer than others, but even our poor are generally better off than most residents of the so-called developing world); we are fearful about losing this way of life. We of the developed nations seem to load epidemics with anxieties about death or the collapse of society. Sometimes we are right to be afraid of cataclysmic disease. The Black Death was a sudden catastrophe. Usually, though, nature is subtler.

The deeper answer, and the one this book explores, has to do with anxieties that go beyond the normal dread of death or destitution. To judge by our response to epidemics that are less sudden or catastrophic than the Black Death, we fear much more besides: strangers, flying things, modern technology, female sexual desire, racial difference, parenting, the food we eat, and so on. These concerns, beyond the simple dread of death, are part of our makeup. They identify us as citizens of the society we live in and distinguish our world from the ancient world of demons. The way we have responded to epidemics like polio, AIDS, and SARS, and the way we are currently responding to obesity, autism, and addiction, reveal that we bring fears to the prospect of any sort of epidemic, deadly or not.

This book looks at epidemics throughout Western history, going back to the Greeks and Romans, moving up through the Black Death and the development of

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epidemiology in the nineteenth century, and continuing to the present day. It looks at epidemics from three different perspectives. First, an epidemic registers as a physical event: there is a microbial disturbance in an ecosystem with accompanying shifts in the well-being of different human populations. An epidemic also plays a role in social crisis: the illness and death that spread widely act as destabilizers, disrupting the organization of classes, groups, and clans that make up the society we know. Finally, an epidemic has an identity as a narrative that knits its other aspects together: we tell ourselves stories about ourselves, accounts that make sense of what we see happening as well as what we fear (and hope) will happen. These three aspects of the epidemic can’t be divorced from one another: all significant spread of illness also creates a social phenomenon; every social crisis moves us to make sense of it; each revision of the story of our society alters the way we study disease (and even how we define illness) and changes the pitch of social change. To read the history of epidemics is to follow a long story of the fears that go beyond the dread of death, the anxieties that make us who we are.

Epidemics often start with an outbreak of disease, but not always—and not all disease outbreaks spark us to tell an epidemic story. The so-called Spanish Flu of 1918 was the most acutely devastating outbreak of all time, with upwards of 40 million deaths worldwide in barely a year. Camouflaged by World War I, or perhaps just too catastrophic to dwell on, the flu outbreak registered hardly at all in the Western imagination, at least to judge by the absence of mention in literature or art for decades afterward. Then, in the 1970s, it became not just an epidemic but a central element of the epidemic imagination when scientists who were interested in promoting their theory that devastating flu outbreaks occur every decade or so made the 1918 outbreak an object of historical interest. Today, all discussions of flu involve some retrospection on the Spanish Flu epidemic, the rationale for “pandemic preparedness.” There is an imagined epidemic that carries meanings not self-evident in the original event.

Some epidemics start without any disease being in evidence at all, as the creation of today’s obesity epidemic reveals. An epidemic is a story that has different morals for different “readers”: it teaches various lessons, follows differing accounts (depending on who is telling us what is happening), and can be a sounding of the alarm or a lament or an admonition. This book tells the story of epidemics—of how the way of looking at disease outbreaks affects what people see when there is one, and how, in turn, the epidemic we see changes how we act and what we fear. The story changes as society changes. As such, it has the capacity to illustrate the times in question and reveal the people themselves.