Disease has been with humanity for as long as we have roamed the Earth, and McNeill skillfully retells our collective narrative through the prism of illness. The argument can be made - is made, by this book - that infectious disease has been a significant contributor to seismic shifts at key moments in human history. From the domestication of animals to the adoption of sedentary agriculture, from the growth of cities to the transoceanic exchange, from military conquest to medical advances, disease has been both cause and effect. The alert reader will expect some of the topics McNeill covers - the Black Death, importation of Old World germs to the New, vaccines, a newly-added chapter on AIDS - but some is new ground. The role of the Mongol Empire as an Asian-European disease pipeline, for instance.
The book is scholarly and yet readable, my favorite combination. I found the monograph most compelling when it dedicated space to one of the most important aspects of the story: the social construction of disease. Our comprehension of bodily afflictions is in no small measure viewed through the lenses of class, race, and other social constructs. How we perceive various diseases informs and impacts how they are treated. Much of this is founded on who suffers from these diseases, and who does not. In the Middle Ages, for instance, Jews were disproportionately unaffected by the bubonic plague. This fed into Christian persecution of Jewish populations, as Jews were blamed for having concocted the Black Death with their Hebraic wizardry and visiting the epidemic on their gentile victims. Historic epidemiology reveals that Jews were less devastated by the plague because they were forbidden from owning farms or waterfront wharfs (where the plague would flourish with plentiful flea-bearing rats), and were consigned to insular ghettos that served as de facto quarantine zones. There is also research that kosher food preparation also helped to limit the spread of the disease. None of this mattered to the medically ignorant leadership of the day - what mattered was that casual observation supported existing bias, and that's an easy formula for doubling-down on prejudice.
In our own living memory, the same social phenomenon played out on the other side of the coin regarding HIV and AIDS. In this case, a disenfranchised population with limited political power suffered disproportionately from a poorly-understood disease, and extant bigotry readily explained what medical science was still struggling to unpack. It was only when non-homosexual patients began to contract AIDS in greater percentages that treatment of the affliction became mainstream. Social construction of disease matters.
We continue to struggle with this very real problem today. Mental health and substance abuse are two areas where social construction of disease hampers our collective capacity to address staggering medical problems. When crack was devastating poor black urban populations in the 1980s and '90s, addiction was widely perceived as a criminal justice problem. Now, as heroin and other opioids are killing our affluent white neighbors, we are far more likely to consider it a public health issue. This is so important because of how we invest our public treasure in response. More cops on the street for supply interdiction compared to treatment and recovery resources remains a huge and ongoing debate. (We know that the latter is far more effective and efficient and equitable than the former, but that's a conversation for another day.) When populations of higher social status and political power suffer from a disease, we're all about brightly-colored lapel ribbons and fundraising walks. When affected populations are those in our modern political ghettos, we're far less likely to mobilize social or financial capital in response.
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