Book reviews

References

Cresswell, T. (1993) ‘Mobility as resist- ance: a geographical reading of Kerouac’s “On the Road” ‘, Transac- tions of the Institute of British Geog- raphers NS, 18 (Z), pp. 249-262.

Duncan, J. (1978) ‘Men without proper- ty: the tramps classification and use of urban space’, Antipode, 10 (l), pp. 24-33.

Sibley, D. (1988) ‘Purification of space’, Environment and Planning D: Society and Space, 6, pp. 40!%421.

H. Parr

University of Wales, Lampeter

The Coming Plague: Newly Emerg- ing Diseases in a World Out of Balance L. Garrett New York, Farrar, Straus and Giroux (1994) 750 pp, $25.00

Disease in Evolution: Global Changes and Emergence of Infectious Diseases M. Wilson, R. Levins and A. Spiel- man (eds) New York, New York Academy of

Sciences, Annals Volume 740 (1994)

503 PP

In 1994, two very different books were published on essentially the same theme-the emergence of in- fectious diseases and the possibilities for their rapid global transmission. The first by L. Garrett, a health and science writer for Newsday, is what I would call a pro bono public0 book, an exposition for the layperson, meticulously researched, written in a compelling narrative form that makes you want to turn the next page. The second, consisting of many specialized papers and discus- sion, arose out of a Woods Hole conference sponsored at the end of 1993 by the Harvard School of Public Health. It brings together some of the best, but still preliminary, think- ing about the manner in which infec- tious diseases can emerge in particu- lar regions, only to move out of their initial places of origin. It is worth noting that the author of the first book was a prominent participant in the second. Both books are im- mensely rewarding, and both will be of value to wide audiences ranging from specialist epidemiologists,

medical geographers, earth scien- tists, and the general public.

In many respects, the style of The Coming Plague is reminiscent of Randy Shilts’s magnificent piece of journalism And the Band Played On, except that the range of diseases is much broader. The book starts with the Bolivian hemorrhagic fever, an infection of the Machupo virus that causes every capillary in the body to leak, usually bringing death by car- diac arrest. There is no cure, except to maintain bodily fluids until the immune system has time to kick in. But what a chain of events lies be- hind such bald statements: a social revolution extends agriculture sud- denly into the dense forest, which disrupts the natural habitat of a field mouse, whose urine carries the virus. The mouse population explodes on the new source of human food, espe- cially in the virtual absence of cats, whose own immune systems have been destroyed by a regime of DDT spraying so intense that it leaves a film of white powder on many sur- faces in poor Bolivian villages. Am- plified up the food chain, its effects are literally devastating. The best- laid schemes o mice an men Gang aft agley, as poets well know. And so the list of ‘new viruses’ grows- Marburg, Lassa, Ebola, hanta-each with an extraordinary story of epidemiological astuteness and cour- age lying behind it.

But interspersed with chapters on specific diseases are much deeper discussions of the conditions that en- hance the emergence of such ‘new’ viruses and their rapid transmission over regions, nations, and some- times continents, to make them truly global pathogens. The human im- munodeficiency virus figures prom- inently in these discussions, but the chapters are by no means a simple retelling of the AIDS story. What, in fact, are these conditions that en- hance appearance, transmission, and sometimes devastation? A potpourri that is difficult to separate into its separate parts except for the pur- poses of linear narrative. First, ex- ploding human populations that put increasing pressure on fragile eco- systems, whether the pressures are Japanese logging companies raping a

tropical forest in Southeast Asia, or poverty-stricken displaced peasants burning the Amazonian rainforest. Most of the increase takes place in exploding Third World cities in which water supplies are increasingly contaminated and modern sewage for the most part nonexistent. Second, a desperate poverty that is observable at all geographic scales; between North and South, between town and country, between rich and poor. Diseases, new or old, tend to go hand in hand with wretched hu- man conditions. Third, a prodigal use of antibiotics and pharmaceutical drugs that turn people into walking environmental ‘niches’, where the evolutionary machines we call viruses, bacteria, and parasites can mutate or recombine to produce re- sistant forms. Fourth, the simple fact that few of the world’s 4028 airports are more than 36 hours away from any other.

Nor do we need what Garrett calls ‘Thirdworldization’ to enhance the appearance of new diseases: right here at home, Legionnaire’s Disease appears in affluent hotels with mod- ern air conditioning and jacuzzi baths. Toxic shock syndrome appears where superabsorbent and petrochemically perfumed tampons of artificial fibers tear cells from dry vaginal walls to produce lesions and ulcerations through which a new strain of Staphylococcus aureus- totally immune to all penicillin antibiotics-passes with ease. The bacterium Cryptosporidium pro- duces a strain that is not only chlorine-resistant but can actually live on Clorox. It devastates people with already compromised immune systems. We also have our Third World pockets, inner-city ghettos surrounded by affluent suburbs.

As might be expected, Disease in Evolution is a book different in structure, with eight parts composed of separate scientific papers and the subsequent discussions they pro- duced. Many diseases are related to water-fresh or salt-and six papers focus on cholera and seafood toxins, followed by 14 plates of color- enhanced, remotely sensed images indicating the sort of useful things we can now record visually-tempera-

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Book reviews

gress that has been made in resolving these issues should not be surprising, since it reflects the problematic that is AIDS.

The essays vary in length, perspec- tive and quality. The lack of effective use of geographic research tech- niques, or mapping in general, is disappointing. The ‘social aspects’ perspective is narrowly defined as sociological or institutional, primari- ly focusing on organizational be- haviour and policy-making, while a few authors take a cultural studies perspective. Several chapters discuss similar issues, such as the con- troversy over the term ‘Men having Sex with Men’ (MSM), programs working with male prostitutes, and the ‘new public health’. At the same time, the institutional focus dis- appointingly means that no articles broach topics such as the controversy over lesbians as a risk category, con- textualizing incidences of AIDS, or relating AIDS to its ‘place’, geo- graphically or historically.

The first four chapters provide an institutional overview of the volun- tary sector, HIV/AIDS services, pri- vate workplace policies, and ‘new public health’ approaches to com- munity change. Each is an adequate survey of the area but provides little new insight into the overall problems of institutional approaches to the epidemic. For instance, Goss and Adam-Smith survey workplace AIDS policies. They find policies are either ‘defensive’ or ‘humanistic’. Companies with defensive policies are concerned about the spread of the epidemic within the workplace, while those with humanistic policies emphasize ‘treating HIV/AIDS as an issue which . . involves all em- ployees’ (p. 39). While simplifying their argument slightly, the quote gives a reasonable indication of the comparisons made within the policy analysis. The distinctions seem very clear, either bad or good, but one wonders if reality is so uncompli- cated.

The fourth essay, Rhodes’ interest- ing discussion of new approaches in community public health, while leaving the reader dissatisfied with his conclusions, serves as a prologue to the following discussions of how

tures, chlorophyll, biomass, phyto- plankton, etc. Let a meander of the warm Gulf Stream ride up and over the shelf near Hatteras (normally cooled by a coast-hugging tongue of the Labrador Current), and Gym- nodinium breve, with its dinoflagel- late toxin, means a $25 million loss to the local fishing industry for the next six months, quite apart from 48 cases of neurotoxic poisoning.

But most diseases are terrestrial, often vector-borne. Ten papers range over arbovirus (arthropod borne) diseases, of which there are now over 100 (in addition to the classic yellow, dengue and pappataci fevers), including Lyme, encephali- tis, oropouche, rift valley and hanta- virus diseases. Modeling diseases is still at an extraordinarily simplistic stage, and the section dealing with such topics is, frankly, disappoint- ing. Most efforts are totally aspatial (a contrast made more vivid by the sense and awareness of geographic space and place in many other parts of the book) and consist of differen- tial modeling down the timeline to produce streams of numbers whose values simply reflect the initial guess- timates to which they were mechani- cally coupled. Spatial modeling seems to be limited to an example of stochastic automata, which produces pretty pictures for The Scientific American but very little insight ab- out real epidemics taking place in spaces highly structured by physical conditions and the human presence. Epidemiologic modelers need to forget what they were taught in graduate school and raise their sights. Many of them would be helped by the papers in Part V on theoretical and social approaches, especially those by Garrett, Chen and others who seem to be more than intuitively aware of the import- ance of human movements.

The sheer complexity of the prob- lems of emergence and transmission at a global scale are well brought out in Part VI, ‘Surveillance’, and Part VII, ‘Conceptual framework’. ‘Sur- veillance’, by definition, is routine and generally unexciting. It is also literally crucial for timely response, as a number of ‘sentinel networks’ have demonstrated. As for concep-

tual frameworks, these remain weak, and I think for three reasons: first, the sheer complexity of monitoring the human family, its disease vec- tors, the environment, and all the other things that can be chained together to produce the sudden em- ergence of a ‘new’ pathogen; second, there still seems to be more than a lingering predilection for defining ‘real’ science as the ability to predict, an act that places us close to the gods, rather than acknowledging both our mortal finitude and the idea that even good science can be achieved through careful monitoring and observation; and third, the spa- tial dimensions of human existence, the sheer ‘whereness’ of places and the connections between them, must move from a few pious genuflections to the ‘geographic’ to an intense awareness that so deeply informs epidemiological thinking that ‘spa- tiotemporal’ is indeliby embossed on all future research.

Taken together, these books would make a nice pair for a course or seminar, the first providing a dramatic human setting for the more sober scientific reports and discus- sions. Both are enhanced by good maps (Garrett), images, diagrams, references and indexes, allowing further exploration of the many problems they raise.

Peter Gould Pennsylvania State University

AIDS: Foundations for the Future P. Aggleton, P. Davies and G. Hart

(eds) London, Taylor and Francis (in the ‘Social aspects of AIDS’ series edited by P. Aggleton) (1994)

These essays, taken from the 1993 conference on the ‘Social aspects of AIDS’ held in London, cover an array of issues. However, since the complex realities of sexual orienta- tion and identity, and the vague or varied definitions of ‘risk groups’ and communities, have run through the entire narrative of the epidemic, the frequency with which the authors once again grapple with them is not surprising. Perhaps the lack of pro-

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