key: cord-0001106-dxbbg4td
authors: Panosian Dunavan, Claire
title: This Zoonotic World
date: 2013-04-03
journal: Am J Trop Med Hyg
DOI: 10.4269/ajtmh.13-0092
sha: 33ca94e310160a0d80e15f1d2bbd2379485789d7
doc_id: 1106
cord_uid: dxbbg4td

nan

TRACKING THE "NEXT BIG ONE" Since its release, readers and reviewers have flocked to "Spillover" like flies to carrion, if you'll pardon the scabrous image. Or, to milk the metaphor: like buzzing green-bottles to a still, viral victim in a far forest glade.

There's no denying our 21st century fascination-both mordant and self-protective-with emerging, zoonotic infections. My epiphany came while reading Karl Taro Greenfeld's book on SARS. In my Los Angeles Times review of "China Syndrome: The True Story of the 21st Century's First Great Epidemic," I tried to depict the fragile boundaries between human, animal, and viral wildlife.

"Picture Guangdong province, circa 2002-land of luck and prosperity," I began. "'To get rich is glorious,' Deng Xiaping had proclaimed years earlier, opening the door to a new era of enterprise. Now, in China's south, music blares, cell-phones ring, cigarette smoke curls, and tycoons flush with cash consume every kind of exotic meat from camel hump to pangolin ear. The growing passion for 'Wild Flavor' cuisine has spawned a flourishing trade. In crowded warehouses, slaughter chambers, and restaurant kitchens slimy with entrails and excreta, hundreds of caged creatures destined for affluent diners nervously await their fate." "Welcome to the riotous breeding ground of severe acute respiratory syndrome, an infection that will soon species-jump from animals to people."

Quammen lures readers with interlocking characters and sub-plots in the SARS drama. To name a few: fish merchant Zhou Zuofeng, the original "Poison King" "super-spreader" of the novel coronavirus. Brenda Ang, the infectious diseases consultant who saw many SARS sufferers (both patients and healthcare workers) at Singapore's Tan Tock Seng Hospital. Esther Mok, Dr. Ang's index case, who contracted her illness at Kowloon's benighted Metropole Hotel and subsequently infected her father, mother, uncle, and pastor-all of whom died.

Quammen then narrates the race to identify the SARS agent and its (still) elusive reservoir host. Finally he joins Aleksei Chmura, an American virus hunter-cum-global gourmand. As a prelude to their fieldwork, the two men bond over clotted pig's blood, bean sprouts, red peppers, and drippy globs of durian, "the world's stinkiest fruit." Then it's off-minus protective respiratory gear-to netting bats in the karst mountains near Guilin and later phlebotomizing them. Wrapping the chapter is an excursion to a cinderblock billet in southern China where Farmer Wei Shangzheng raises placid bamboo rats headed for human dinner plates.

"They breed readily, Mr. Wei, explained. He kept mostly females, plus a few good studs. Last month he sold two hundred rats, and now he was expanding his operation, building new sheds. Already he was the largest bamboo rat farmer in southern China! He told us exuberantly. Southern China, yes, and maybe beyond! He stated this not to brag, it seemed, but in joyous amazement at the vagaries of fortune. Business was good. Life was good. He laughed-ha ha ha!-at the thought of life's goodness. He's famous! He told us. He had been featured on Chinese TV! We could Google him! His ventures in bamboo-rat husbandry began in 2001, when he lost his job at a factory and decided to try something new.

The rat meat was mild, subtle, faintly sweet. There were many small femurs and ribs. One eats bamboo-rat hocks with one's fingers, I learned, sucking clean the bones and piling them politely on the table beside one's bowl, or else dropping them on the floor (the preferred method of Mr. Wei's father, a shirtless old man seated to my left) where they would be scavenged by the skinny cat who slept under the table. The hotpot was scorching. Mr. Wei, an exemplary host, brought out some big bottles of Liquan beer. Guilin's finest brew, nicely chilled. After a few glasses, I got into the spirit of the meal and found myself turning back to the rat platter, browsing for choice morsels.

I had begun to see Aleksei's point: if you're a carnivore, you're a carnivore, so what's the merit of fine distinctions? And if you're going to eat bamboo rat, I figured, best to do it here, at the source-before the poor animals get shipped, stacked amid other animals, and sick. Wild Flavor doesn't need to be seasoned with virus." I've included this passage in its entirety because of its humanity, humor, and unexpected tag-line. Could the same information be packaged in dry, technical prose? Of courseand many of us would be just as enthralled. But not, necessarily, general readers. Lest we forget: it is they who must ultimately grasp 21st century disease ecology, then make savvy, possibly life-and-death choices.

Enough editorializing. It's no easy task to summarize "Spillover." For now I'll simply state that the book brims with engrossing human tales, field investigations, and "directto-camera" riffs around Hendra, Ebola, malaria, Q fever, psittacosis, Lyme disease, Herpes B, Marburg, Nipah, HIV, and avian flu, among other zoonoses. The book also introduces George MacDonald's model of malaria transmission and Australian scientist Frank MacFarlane Burnet's insights about certain shortcomings of a classical medical education. Burnet published "Biological Aspects of Infectious Disease" after recognizing that MDs trained in the first half of the 20th-century often lacked knowledge of zoologic and environmental factors contributing to human infections. Drawing on contemporary field research, Quammen marshals evidence that fragmented and disrupted ecosystems-as opposed to intact and diverse ones-are the settings most vulnerable to modern-day spillovers.

QUAMMEN UN-CENSORED "Let's start with the braided structure of the book. I found it fascinating." "I don't like books that are structured in obvious, programmatic ways. The last thing I wanted was to write a book that simply covered nine diseases and marched predictably through them. So [in addition to disease-by-disease treatment], the history and principles of disease ecology are two more cords. My quest to go around the world to see and learn as much as possible is the fourth thread."

"I was also struck by the humor and empathy of your writing. Where does that come from?" "As a writer, humor is one of those things you don't want to think about too much, but I suppose I was always kind of a smart aleck . . . At the same time, I'm not a hard-nosed journalist; I'm some other kind of non-fiction writer. When I go into the field, it's very hard for me not to like people. Especially if they are unpretentious people like the bamboo rat farmer in China."

"What's your view on our modern-day empathy for animals?" "There's certainly a tension between concern for animals at the population and species level and concern for individual animals. That's something I'm interested in and have written about. I tend to think that animal rights people and conservationists are natural allies . . . but in a lot of cases the best thing for the population status of a species is not the best thing for individual animals." "I also have empathy for plants . . . I had a recent National Geographic assignment climbing the world's second-largest sequoia tree. I had enormous empathy for that creature once I got up into its crown." "Do you have empathy for viruses?" "Aah, that's the sharp edge of the wedge. That's a difficult one." "What about bats-considering the deadly viruses they sometimes carry?" "In the course of researching the book I spent time with bats, helping people like John Epstein and Aleksei Chmura trap and handle them, look for bat-roosts. It gave me more empathy. The one thing I regret [in "Spillover"] is that I didn't more clearly and explicitly say: 'Look, dear readers, do not demonize bats. Bats are enormously important and perform important ecosystem services.'" "What are your thoughts about eradicating infectious diseases?" "There's an absolute-ness about eradication that I distrust, that makes me uneasy . . . In the case of zoonoses, of course, we can't eradicate unless we cure or eradicate the reservoir host. We don't want to pave this entire planet to make it cleaner and safer for humans because it will be not only un-helpful, it will be boring, lonely, and ugly." "I do have sympathy for people who say: we've eradicated smallpox from the human population, now let's eradicate polio. How can you not be in favor of that? But zoonoses are much more complicated. As Rick Ostfeld [of the Cary Institute of Ecosystem Studies in Milbrook, NY] once said to me: 'Infectious disease is inherently an ecological system.'" "What was your scariest moment researching the bookand your most poignant?" "The scariest moment was when-about a-third into it-I started waking up in the middle of the night thinking: how am I going to do this? I've signed a contract; my editor and my agent are counting on me to deliver an encyclopedic and entertaining treatment of zoonotic diseases, including AIDS and Ebola. How in the world am I going to get access? Then, someone said: 'Do you want to go with me to southern China and look for SARS?' 'Do you want to go to Bangladesh and draw blood from macaques?' . . . and the moment passed. Then it was just a matter of, well, don't fall off the roof." "The most poignant moment was when I went back to that village in the Congo with Prosper Balo and he told me the story of when Ebola struck his village. Balo [an expert gorilla tracker] was off working in the forest where gorillas were dying; meanwhile his wife [whose sister, two brothers, and child died of Ebola] was being shunned, people wouldn't touch her money, wouldn't sell things to her. He lost members of his gorilla family; then he went back to his compound where he lost members of his human family. At that moment I thought: here is a complete human being. And I am completely interested in his story."

"What do you say when people ask you to predict the 'Next Big One'?"

"I try to say what I say in the last chapter. It's more complicated than that. Yes, there is a possibility but not an inevitability that a pandemic will kill millions or tens of millions of people. But it's also possible we can control or avert that." "People need more information to make intelligent choices. One reason I wrote the book . . . [is to] improve decisionmaking. We have to keep fighting the battle of getting people vaccinated for flu just as we have to keep fighting the battle to prevent people in Bangladesh from drinking raw date palm sap [and getting Nipah virus] ." "My book is not a haiku, it is not a street sign, it is not even an op-ed . . . it's a 500 page book. I don't think of it as a strident alarm bell. I think of it as a nonfiction concerto on a very, very important field of science."

ASTMH CONFIDENTIAL Several times during our conversation, Quammen reiterated his debt to the scientists who helped him complete his "concerto." Not surprisingly, "Spillover's" back-matter is packed with names, including those of ASTMH members.

Quammen first met Jens Kuhn at a filovirus meeting in Gabon. "Actually, we were both staying at the same fringe hotel outside Libreville," Quammen clarified; while traveling back and forth on the bus, the two men hit it off. Would Kuhn read a draft of his Ebola chapter? the writer asked. In exchange for a bottle of single-malt scotch (he declined a case), Jens reviewed the entire manuscript.

Another reviewer was Charlie Calisher, whose 2006 review article, "Bats: Important Reservoir Hosts of Emerging Viruses," figures colorfully in a chapter entitled "Celestial Hosts." Quammen describes Charlie as ". . . a smallish man with a dangerous twinkle, famed throughout the profession for his depth of knowledge, his caustic humor, his disdain for pomposity, his brusque manner, and (if you happen to get past those crusts), his big, affable heart." Finally, Karl Johnson. "Tremendously good company and such a silverback in this field," Quammen said of his fellow Montanan and fly fisherman. Karl not only briefed Quammen on Machupo, Ebola, hantavirus and other 'special pathogens' studied at Johnson's former CDC branch, he set the record straight on tumid features of Ebola promulgated by Richard Preston's "The Hot Zone." "Bloody tears is bullshit. Nobody ever has ever had bloody tears," our past-President declared, adding "People who die [of Ebola] are not formless bags of slime." (To his credit, Preston accepted the knuckle-rap with evident grace in his Wall Street Journal review of "Spillover.") After we spoke, I mailed Quammen a copy of ASTMH's Karl Johnson video. I also threw in a reprint of "Infectious History," Joshua Lederberg's prophetic essay published in 2000. In a section titled "Evolving Metaphors of Infection: Teach War No More," Lederberg argues for moving beyond the traditional allegory of "microbe v. man" (or, to paraphrase the Nobel laureate microbiologist: the manichaean "We good; they evil" view). Re-reading Lederberg, I found echoes of Quammen, whose final chapter offers this thought on the "salubrious" side of zoonotic diseases:

"They remind us, as St. Francis did, that we humans are inseparable from the natural world. In fact, there is no "natural world," it's a bad and artificial phrase. There is only the world. Humankind is part of that world, as are the ebolaviruses, as are the influenzas and the HIVs, as are Nipah and Hendra and SARS, as are the chimpanzees and bats and palm civets and bar-headed geese, as is the next murderous virus-the one we haven't yet detected."

Or, as Quammen reflects after Prosper Balo shares a treasured notebook listing the names "Apollo," "Cassandra," "Afrodita," "Ulises," "Orfeo," and other Ebola-felled apes: "People and gorillas, horses and duikers and pigs, monkeys and chimps and bats and viruses: We're all in this together." CLAIRE PANOSIAN DUNAVAN E-mails: cpanosian@mednet.ucla.edu or drclairep@aol.com

Biologic Aspects of Infectious Disease

Bats: important reservoir hosts of emerging viruses

China Syndrome: The True Story of the 21st Century's First Great Epidemic

Pathways of discovery: infectious history

The Subject is Science, the Style is Faulkner. The New York Times

Panic Attack. The Los Angeles Times

Hunting the Next Pandemic

Song of the Dodo: Island Biogeography in an Age of Extinctions

Monster of God: The Man-Eating Predator in the Jungles of History and the Mind

The Reluctant Mr. Darwin: An Intimate Portrait of Charles Darwin and the Making of His Theory of Evolution

Spillover: Animal Infections and the Next Human Pandemic