The Plague Cycle

by Charles Kenny

  Improving global pandemic preparedness wouldn’t take a huge amount of money. The Commission on a Global Health Risk Framework for the Future estimates that $4.5 billion a year would buy strengthened national health systems, funding for research and development, and financing to address the most urgent weaknesses in global health security.

  Preparing and responding to pandemic threats can’t be left in the lap of poorer countries. Not only is it not moral; it isn’t practical. Ultimately, rapidly spreading infectious disease becomes a problem for all of us wherever it starts, even if the pain is often disproportionately inflicted on poorer regions. We need to ensure that every country has the financial and technical support to confront new threats. That’s how the plague has become a minor concern worldwide and how smallpox was eradicated—and it’s what the planet needs to achieve with Covid-19 and the pandemics that come after.

  The medical and sanitary advances that took place in the twentieth century transformed the world. There’s no reason that such advances should stop in the twenty-first. The planet has never been richer—able to afford more research and better disease response. At a cost simply dwarfed by the benefits we can resume our global progress against infection.

  CHAPTER TWELVE Conclusion: Humanity’s Greatest Victory

  An image from Albrecht Dürer’s The Apocalypse, featuring the Four Horsemen of the Apocalypse. The rider with the bow is sometimes identified as representing pestilence. (Source: The Revelation of St. John: The Four Riders of the Apocalypse. Albrecht Dürer, 1497–98. Wikimedia Commons.)

  In the Bible’s Book of Revelations, the Four Horsemen of the Apocalypse are sent forth to “kill with sword and with famine and with pestilence and by wild beasts,” and carry off a quarter of the earth. The identities of the horsemen are a matter of some debate: the fevered poetry is hard to decipher. While the Fourth Horseman seems to be Death himself, the Third Horseman is universally recognized as famine, and the Second as war, argument rages over the identity of the First Horseman: some recent experts suggest he is pestilence, others argue that he is Jesus Christ or the embodiment of righteousness.

  It’s ironic that pestilence occupies the disputed saddle, for while throughout most of history violence and famine were two of Death’s most useful tools, the only one of the three that has ever managed to carry off a quarter of the earth at one go is pestilence. Plague ended the age of antiquity and ushered in the Renaissance. Infection shaped the age of global empires, and its decline boosted the economy of the modern world. Neither violence nor famine can claim to be its equal.

  The frequency of violence, pestilence, and famine combined is why the idea that a good life should be one free of tragedy was mocked as utopian until the Industrial Revolution. They are the tools that nature used to keep humans in Malthusian misery. And none—famine, violence, or pestilence—has nearly the grip on humanity that it had even fifty years ago. A huge part of that progress is due to the fight against infection, flattening the plague cycle, and their knock-on effects.

  The extent of disease has always shaped economic and social relations. Pandemics from centuries ago still help determine wealth and poverty, democracy and autocracy to this day. But the last half century clearly demonstrates that not all trends are inexorable. We’ve seen a massive global improvement in the quality of life even in parts of the world that suffered the most from the arrows of the First Horseman through the last two thousand years. Malthusian fatalism had a declining empirical basis in the nineteenth century. Now it has no basis at all.

  The tragedy of Covid-19 helps illustrate the utterly different world we’ve become used to living in. The most alarming early forecasts suggested that if governments and individuals did nothing to respond to the new threat, as many as 2.2 million Americans might die from the coronavirus.1 That amounts to about six out of every one thousand people in the country. Such forecasts were one factor behind an appropriately massive global response. But in the US in 1900, eight out of every one thousand people died from an infectious disease, and that wasn’t an unusual year.2 For much of human history, it’s unlikely that an illness like Covid-19 would have been recognized as a new and distinct health threat at all.

  If we continue on the path away from Malthusian doom, which we know how to do, how will the world appear different? With declining birth rates and longer lives, it will undoubtedly be older—but the changes go beyond that. Given the links between infection risk and xenophobia born in prehistory, a less infectious world will be friendlier, more cooperative, and less violent. And given the close link between the rise of infection and the subjugation of women at the dawn of civilization, perhaps it will be more equal. If the pandemic tragedies on the scale of Justinian’s plague, the Black Death, and the Atlantic disease exchange go unrepeated, it will be more stable. As good health boosts productivity, countries will be richer and more urbanized—and the gap between industrial and developing countries should continue to shrink. It won’t be a perfect world, but it will continue getting better.

  Or perhaps Covid-19 is only a foretaste of even worse to come. Perhaps we’ll backslide. If anti-vaccine prophets peddle their deadly disinformation without response, if our last antibiotics are wasted on adding a few ounces of white meat to a chicken breast, if we do nothing to improve global cooperation, surveillance coverage, and rapid response to outbreaks, we know what the world will look like. A planet without our most effective tools against infection is one moving back toward Malthusian misery. It’s a world where our view of mortality as an increasingly private affair is blown away by mass burial of the young. It’s a world that is poorer, more violent, more insular—a bigoted and misogynistic place.

  The role of disease in global affairs has implications for national security: until we reach global targets to reduce nuclear weapons stockpiles close to zero, the most straightforward way for humanity to rapidly roll back decades or even centuries of progress remains the intercontinental ballistic missile. But the world now surely recognizes that pestilence may be the more likely source of a millennial global catastrophe—certainly the First Horseman rides ahead of terror, climate change, or a collapse in food production.

  Meanwhile, “neo-Malthusians,” concerned with the carrying capacity of the planet, are looking at the wrong threats. For them it is shortage—famine brought on by too many people and not enough resources—that spells doom. But while the threat of global famine may stalk in the rear if we don’t move onto a more environmentally sustainable course of production, pestilence remains the more immediate issue. And given that it was lack of technology (rather than of agricultural land) that kept people poor throughout most of history, it makes sense to assume that sustaining the advance of technology is the process by which we’ll ensure 9 billion plus people can live on the planet in harmony.

  The history of infection teaches a particular lesson to those who want to withdraw from international cooperation: if disease becomes the excuse for closing borders and deploying force, the costs to global progress will be immense. We don’t have to accept a new pathogen as the will of God—nor are flight, fortresses, or imprisonment our only defense against the scourge.

  Because, for all of the failings and unnecessary deaths of the response to Covid-19, our scientific advances, our health institutions, and global cooperation have put us in an immeasurably better place to fight it than where Petrarch stood with the plague or Montezuma with smallpox. We still face immense risks, but they can be managed without mass coercion. If we use our tools and technologies wisely, there should be little need to resort to the prehistoric defense of exclusion and the dislocation and poverty that accompany it.

  * * *

  Our progress against infection hasn’t been an unalloyed good. Not least, it has allowed colonization and total war on a scale unimaginable when imperialists perished in new disease environments and armies wilted under the death rates of typhus and dysentery. But think of a young child—for me, it is one of two daughters. For you it might be a gran
dchild, cousin, or niece. Now think of that child retching, then vomiting—once, and then again. Imagine her hot to the touch, unable to control her bowels, crying, scared. She becomes weaker, unable to sit up, chest heaving with the struggle of breath. Finally she grows quiet, that silence more fearful than the cries that came before. Her eyes stare listless into space; she’s semi-comatose, slipping toward death.

  And then think of another child, and imagine it all over again. And then again, five seconds later. And again, twelve times a minute, every minute, of every day. Worldwide, that is about the frequency of under-five deaths. It’s a tragedy—and a stain on the world’s conscience—that far too many children still die of easily preventable conditions every day. But if we had the global child mortality rate of the 1950s, it would be closer to one death every second, five times the level of today—such is the scale of the First Horseman’s retreat.

  Covid-19 temporarily and tragically reversed progress against infection. But still, far fewer parents than ever before in history go through the pain of burying their own children. The massive decline in premature death is something we should celebrate and protect as humanity’s greatest triumph.

  Acknowledgments

  Many thanks to Rafe Sagalyn for advice and participating in numerous conversations on the shape and structure of the book; Patrick Fitzgerald and Felix Salmon for proposing reorganization and focus; Erle Ellis for insights on land use modeling; Charles C. Mann for detailed and helpful comments and corrections on the early chapters; Paul Offit for reading the text to check for medical mistakes; and Dorothy Porter, Justin Cook, Rodrigo Soares, and David Wootton for catching errors and making suggestions relating to tone and presentation. I apologize for the errors that have slipped under their notice or slipped in since they read drafts. Thanks, too, to Rick Horgan for considerable editorial advice and adjustments.

  About the Author

  COURTESY OF THE CENTER FOR GLOBAL DEVELOPMENT

  CHARLES KENNY is a senior fellow at the Center for Global Development; a former senior economist at the World Bank; the author of two previous books about human progress, Getting Better and The Upside of Down; and a contributor to such publications as the Wall Street Journal, Time, The Atlantic, The Economist, and Foreign Policy. He has taught at the Johns Hopkins School of Advanced International Studies and has a PhD in development studies from the University of Cambridge.

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  Notes

  Preface

  1. Jenny Liu et al., “Malaria Eradication: Is It Possible? Is It Worth It? Should We Do It?” Lancet Global Health 1, no. 1 (2013): e2–e3.

  2. See David Wootton, Bad Medicine: Doctors Doing Harm Since Hippocrates (Oxford, UK: Oxford University Press, 2007); Shapin’s review “Possessed by the Idols” in the London Review of Books 28, no. 23 (2006), and Wootton’s response in the next issue.

  3. It’s foolish to judge people in the past by modern standards. Ancient doctors didn’t all practice malignant quackery and patients clearly saw some value in their services. We can learn much from the “wrong” turns of past scientists—as much as from the “right” ones. Again, that a person invented a medically effective treatment or cure doesn’t make them morally pure, and their path to that solution might have involved irrationality or been blazed by means of theories we view today as incorrect. Conversely, people who opposed theories that modern science accepts sometimes did so for reasons that we might find admirable. That said, I don’t believe it’s an overreach to suggest that lower premature mortality is something that would have been valued in the past or that doctors were frequently seen to be of little use in preventing such mortality. Again, it is not the “judgment of history” that Jenner’s development of vaccination was to be celebrated, but the judgment of his contemporaries, including British members of parliament who twice voted him prizes.

  Chapter One: Malthus’s Ultimate Weapon

  1. Thomas Robert Malthus, An Essay on the Principle of Population; or A View of Its Past and Present Effects on Human Happiness, an Inquiry Into Our Prospects Respecting the Future Removal or Mitigation of the Evils Which It Occasions, edited with an introduction and notes by Geoffrey Gilbert (Oxford, UK: Oxford University Press, 2008), Chapter VII, p. 61.

  2. Recent evidence points to sedentism predating agriculture by as much as three thousand years in the Near East, however, suggesting a complex relationship between the growth of agriculture and cities. Anna Belfer-Cohen and Ofer Bar-Yosef, “Early Sedentism in the Near East,” in I. Kuijt (ed.), Life in Neolithic Farming Communities: Fundamental Issues in Archaeology (Boston: Springer, 2002).

  3. Max Roser, “Child Mortality,” published online at OurWorldInData.org, 2016. Retrieved from https://ourworldindata.org/child-mortality/.

  4. Max Roser, “Fertility,” published online at OurWorldInData.org, 2016. Retrieved from https://ourworldindata.org/fertility/.

  5. Data from the Maddison Project website, http://www.ggdc.net/maddison/maddison-project/home.htm, 2013 version.

  Chapter Two: Civilization and the Rise of Infection

  1. Analysis also suggests Mitochondrial Eve lived longer ago and some distance from Biblical Eve. In the seventeenth century, Bishop Ussher of the Church of Ireland added up dates and ages in the Old Testament and suggested the world was created on the evening of Sunday, October 22, 4004 BCE. On that basis, Adam’s wife came to life only about six thousand years ago. Ewen Callaway, “Genetic Adam and Eve Did Not Live Too Far Apart in Time,” Nature, August 6, 2013, http://www.nature.com/news/genetic-adam-and-eve-did-not-live-too-far-apart-in-time-1.13478.

  2. Mark Nathan Cohen, Health and the Rise of Civilization (New Haven: Yale University Press, 1989), p. 18.

  3. Rosemary Drisdelle, Parasites: Tales of Humanity’s Most Unwelcome Guests (Berkeley: University of California Press, 2010).

  4. Cohen, Health and the Rise of Civilization, pp. 33–35, cross-checked with Nathan D. Wolfe, Claire Panosian Dunavan, and Jared Diamond, “Origins of Major Human Infectious Diseases,” Nature 447, no. 7142 (2007): 279–283.

  5. Cohen, Health and the Rise of Civilization, pp. 36–37.

  6. See Wolfe et al., “Origins of Major Human Infectious Diseases.”

  7. Modern Stone Age populations have infant mortality rates largely below (and often considerably below) 25 percent—far lower than rates across Europe and the Americas for much of the nineteenth century. And these rates are likely higher than prehistoric rates because modern hunter-gatherer groups have been subject to most of the diseases of civilization. Cohen, Health and the Rise of Civilization, pp. 82–84, 100–101.

  8. Cohen, Health and the Rise of Civilization, pp. 195–197.

  9. Renee Pennington, “Hunter-Gatherer Demography,” in Panter-Brick et al., Hunter-Gatherers: An Interdisciplinary Perspective (Cambridge, UK: Cambridge University Press, 2001), p. 170.

  10. Cohen, Health and the Rise of Civilization, pp. 87–88.

  11. Azar Gat, “Proving Communal Warfare Among Hunter-Gatherers: The Quasi-Rousseauan Error,” Evolutionary Anthropology: Issues, News, and Reviews 24, no. 3 (2015): 111–126.

  12. See Siniša Malešević, “How Old Is Human Brutality? On the Structural Origins of Violence,” Common Knowledge 22, no. 1 (2016): 81–104, for a discussion.

  13. Vanina Guernier, Michael E. Hochberg, and Jean-François Guégan, “Ecology Drives the Worldwide Distribution of Human Diseases,” PLoS Biol 2, no. 6 (2004): e141.


  14. Robert R. Dunn et al., “Global Drivers of Human Pathogen Richness and Prevalence,” Proceedings of the Royal Society of London B: Biological Sciences (April 2010).

  15. William McNeill, Plagues and Peoples (New York: Anchor, 1996). Certainly, Native Americans on the plains of North America in the nineteenth century were among the tallest people in the world—the health that suggests reflecting not least the low natural disease burden of a sparsely populated hunting ground. Richard H. Steckel and Joseph M. Prince, “Tallest in the World: Native Americans of the Great Plains in the Nineteenth Century,” American Economic Review 91, no. 1 (March 2001): 287.

  16. McNeill, Plagues and Peoples.

  17. Herbert S. Klein, “The First Americans: The Current Debate,” Journal of Interdisciplinary History 46, no. 4 (2016): 543–562. The theory is disputed (see L. Nagaoka, T. Rick, and S. Wolverton, “The Overkill Model and Its Impact on Environmental Research,” Ecology and Evolution 8, no. 19 [2018]: 9683–9696), and there was also a role for climate change (see Anthony D. Barnosky and Emily L. Lindsey, “Timing of Quaternary Megafaunal Extinction in South America in Relation to Human Arrival and Climate Change,” Quaternary International 217, nos. 1–2 [2010]: 10–29).

  18. See Exodus 9:14–15.

  19. James C. Scott, Against the Grain: A Deep History of the First Civilizations (New Haven: Yale University Press, 2017).

  20. There is still some debate as to whether malaria infected pre-civilization humans. Certainly not all strains did, but some may have—see the discussion in Dorothy Crawford, Deadly Companions: How Microbes Shaped Our History (Oxford, UK: Oxford University Press, 2007), pp. 37–46, and Monica Green, “The Globalisations of Disease,” in N. Boivin, R. Crassard, and M. Petraglia (eds.), Human Dispersal and Species Movement: From Prehistory to the Present (Cambridge, UK: Cambridge University Press, 2017), pp. 494–520.