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Dr. Howard Markel
Dr. Howard Markel
At the precise hour when Gov. Gretchen Whitmer, D-Mich., declared an emergency in my home state, and my university’s president ordered an unprecedented shutdown of the entire academic enterprise, I was teaching my undergraduate course on literature and medicine. As coincidence would have it, we were knee-deep in the section on epidemics, and making our way through such classics as Henrik Ibsen’s compelling drama of a public health crisis in a small Norwegian town, “An Enemy of the People,” Katherine Anne Porter’s influenza tale “Pale Horse, Pale Rider,” Larry Kramer’s document of the early years of the AIDS pandemic, “The Normal Heart,” and Sinclair Lewis’s Pulitzer Prize novel of medical research and infectious disease, “Arrowsmith.”
None of these literary works, as brilliant as they are, hold a candle to Albert Camus’s “The Plague,” a remarkable novel I routinely assign to my students. It is, bar none, the best study of an epidemic or pandemic as a social phenomenon that I have ever read. Each year I teach it I not only learn new things, but also walk away expressing wonder at how Camus got everything about an epidemic right.
I was introduced to the novel while still in graduate school after reading an essay entitled “What Is an Epidemic?” by the eminent historian Charles Rosenberg. An intrepid scholar of the devastating cholera pandemics of 1833, 1849 and 1866, Rosenberg used Camus’ novel to characterize the unfolding of an epidemic as a dramatic set of events, usually in four acts, with a distinct but somewhat predictable narrative plot line.
And since I can no longer teach my students in person, I thought a cleaned up version of my tattered lecture notes — on Camus and Rosenberg — might be useful in recommending a good novel while we all shelter in place.
Here’s how it goes:
The first act is one of eye-opening shocks or events. In epidemiological terms, members of a stricken community begin to acknowledge an increasing number of cases and deaths resulting from the spread of a particular contagious disease. Camus’ “Plague” demonstrates this pattern with one of the most memorably disgusting opening scenes in all of literature:
When leaving his surgery on the morning of April 16, Dr. Bernard Rieux felt something soft under his foot. It was a dead rat lying in the middle of the landing. On the spur of the moment he kicked it to one side and without giving it a further thought, continued on his way downstairs. Only when he was stepping out onto the street did it occur to him that a dead rat had no business to be on his landing and he turned back to ask the concierge of the building to see to its removal.
In the pages that follow, Dr. Rieux finds many more dead rats along the streets of Oran, Algeria, but it takes a great deal of hectoring, cajoling, lecturing and—perhaps most critical when chasing after an epidemic—precious time to convince his fellow townspeople that there is, in fact, a serious problem threatening the entire community’s health.
This lethargic response is not restricted to the pages of fiction. Slow acceptance and delayed courses of action in the face of contagious threats are common features in the history of human epidemics. In many circumstances across time, delayed acknowledgment of an epidemic can be explained by how the crisis threatens various vested interests or strongly held beliefs, from the economic and institutional to the personal, religious, and emotional.
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The second act of an epidemic centers on how society responds to a seemingly random, “out of the blue” event like an epidemic, and attempts to understand it. Readers of “The Plague” will recall the argument over the epidemic’s origins between the doctor, who subscribes to a scientific, bacteriological approach to understanding the plague, and the Catholic priest, who preaches that the plague is an act of divine retribution for sinful lifestyles and demands repentance. This dichotomy in understanding deadly disease — with religion or morality on one hand and science on the other — is a hallmark of pandemics past and we must always account for how religious, spiritual and cultural beliefs and practices can mitigate, contain or inflame our current contagious crisis.
Once an epidemic is recognized, the third act begins, and we watch the public demanding that some type of action of some kind be taken. The history of epidemics is littered with tales demonstrating the importance of bold, decisive leadership and the costs of ineffective or incompetent crisis management. As noted by many historians observing the tug of war between the public and those charged with protecting their health, the operative word in public health is “public.” It is essential that our leaders develop a strong public consensus on a plan of actions that takes into account varying cultural values and attitudes, social and class hierarchies, and economic and political imperatives. Reining in spreading infection demands competent and trusted leadership.
The final act is perhaps the most vexing phase of an epidemic, especially for those involved in public health management and epidemic-preparedness planning. Epidemics often end as ambiguously as they appear. Specifically, once an epidemic peters out and susceptible individuals die, recuperate or escape, life begins to return to its normal patterns, and healthy people begin to place the epidemic in the past. Camus perfectly recorded this sense of “global amnesia” — a mind-set that threatens the world for pandemics to come:
… as he listened to the cries of joy rising from the town, Rieux remembered that such joy is always imperiled. He knew what these jubilant crowds did not know but could have learned from books: that the plague bacillus never dies or disappears for good; that it can lie dormant for years in furniture and linen-chests; that it bides its time in bedrooms, cellars, trunks, and bookshelves; and that perhaps the day would come when, for the bane and the enlightening of men, it would rouse up its rats again and send them forth to die in a happy city.
Epidemics and pandemics are living, social laboratories.
They provide windows on the resilience and efficiency of a particular society’s governmental structures, its social strengths and shortcomings, and its engagement with rumor, suspicion, or outright bad behavior. After all, epidemics are hardly quiet occasions; they are experienced and responded to in real time by the affected community and then later re-discovered, heralded, and explained by historians like me — as well as novelists.
As we reflect on how drastically COVID-19 has changed all of our lives, the final few sentences of Camus’ “The Plague” may well represent the saddest, and most eloquent, endings in modern literature.
Dr. Howard Markel writes a monthly column for the PBS NewsHour, highlighting momentous historical events that continue to shape modern medicine. He is the director of the Center for the History of Medicine and the George E. Wantz Distinguished Professor of the History of Medicine at the University of Michigan and the author of “The Secret of Life: Rosalind Franklin, James Watson, Francis Crick and the Discovery of DNA’s Double Helix” (W.W. Norton, September ’21).
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