Book Review

Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization

N Engl J Med 2009; 361:830-831August 20, 2009

Article

Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization
By Andrew T. Price-Smith. 281 pp. Cambridge, MA, MIT Press, 2009. $48 (cloth); $24 (paper). ISBN: 978-0-262-16248-7 (cloth); 978-0-262-66203-1 (paper).

The study of the relation between infectious diseases and national security is hardly a new endeavor. In this book, Andrew Price-Smith reminds us that Thucydides, in his 5th-century publication The History of the Peloponnesian War, mused about the profound effects of the Plague of Athens on power, conflict, and governance during the war between the Athenians and the Peloponnesians. Price-Smith advances five hypotheses that focus on causal relations between infectious diseases (the “contagion” in the book's title) and domestic and international instability (the “chaos” in the title). His central contentions are that certain epidemic infectious diseases stress the internal cohesion of nation states; that epidemics may promote economic and political conflict between nation states but that such conflicts do not advance to armed violence; and that national and international strife amplifies the morbidity of epidemic diseases. He supports his arguments by examining the influenza pandemic of 1918 and 1919 and its effects on World War I, the destabilizing effect of human immunodeficiency virus (HIV) and AIDS in Zimbabwe, international finger-pointing in the wake of the emergence of bovine spongiform encephalopathy (BSE, also known as “mad cow disease”) in the United Kingdom, and the threat to international security that was posed by the severe acute respiratory syndrome (SARS) epidemic. Price-Smith's case studies are well researched — particularly his study of World War I, in which he examines previously unpublished data from German and Austrian archives on disease-induced illness and death during the war.

Since the domestic anthrax “attacks” in 2001 and the Iraq war — which was partially justified by its instigators with the national security threat of biologic weapons — the conversation about infectious diseases and national security has been dominated by fear of bioterrorism. This timely book is focused on the sociopolitical implications of epidemic infectious diseases that occur naturally. In 2002, the U.S. National Security Strategy identified bioterrorism and naturally occurring infectious diseases as potential threats to national security. In 2006, the Department of Defense commissioned a RAND study to find out what strategic information is needed to mitigate the effects of naturally occurring epidemics on national security. In the midst of the 2009 H1N1 influenza pandemic, U.S. Secretary of Defense Robert Gates declared that “under pressure from criminals or disease, weak states can become failed states.” Price-Smith would argue that in the public psyche, the specter of emerging infectious diseases should be viewed as a national security problem that is severe enough to be listed alongside terrorism, weapons proliferation, cyber attacks, and other threats that originate from nonstate actors.

Despite the exhortations that infectious diseases and national security are causally linked, Price-Smith's conclusion that “infectious disease operates in a number of ways to destabilize a state from within or to weaken a state to the extent that its ability to project power, and indeed to defend itself, is significantly compromised,” seems incomplete. We cannot deny that health and security are linked, but the causal link between them is weaker than Price-Smith contends. The Spanish influenza virus ravaged combatants in World War I with a fury that was unequaled in the 20th century, and yet it is a stretch to assert that this pandemic materially changed the outcome of the war. Likewise, many sub-Saharan African nations have a record prevalence of HIV–AIDS, but HIV–AIDS is only one factor in their instability. Former president of South Africa Thabo Mbeki maintained power for 14 years (5 as deputy president and 9 as president) despite his shocking denial of the enormous toll of AIDS on his country and of the infectious cause of the epidemic.

The chapter in this book with perhaps the most general interest is an exploration of the question of whether war is a “disease amplifier” that accelerates the emergence and increases the prevalence of infectious diseases. Price-Smith argues that the breakdown of many basic public health institutions during war, combined with malnutrition and the transplantation of refugees into regions with endemic pathogens — to which they have little or no prior immunity — increases the likelihood and consequences of local epidemics. Although Price-Smith's musings about refugee movements as a critical variable for epidemic disease seem geographically limited, the policy prescriptions that flow from this chapter — including support for preventive medicine in areas with conflicts and readiness for medical surges into stricken regions — are certainly relevant and important.

Price-Smith seems to be asking many of the right questions, but his hypotheses and the evidence to support them lack the richer context of the stability of nation states and the more complex, noncausal relationships between “contagion and chaos.”

Jesse M. Klempner, M.A.
CSP Associates, Cambridge, MA 02142
jklempner@cspassociates.com

Mark S. Klempner, M.D.
Boston University Medical Center, Boston, MA 02118