Duel Without End Mankind’s Battle with Microbes

Like every other species on the planet, humans suffer from infectious diseases caused by bacteria, viruses, fungi, and other microorganisms. What sets us apart is a set of nifty tricks—the fruits of several centuries of scientific and medical advances—that allow us to strike back and gain a measure of control. And yet, as Norwegian professor of medicine Stig S. Frøland writes, this is a duel without end: we can win many battles, but we will never win the war.

At the surface of it, this seems like a potted history of celebrity diseases, and the book is written expressly for readers without previous specialized knowledge. However, Frøland brings relevant expertise to the table thanks to his medical background. He structures this book using two frameworks.

The first encompasses the participants—man and microbe—but especially their environmental and ecological interactions, which are partially shaped by human behaviour. These factors include the rise of cities, warfare, infections from (domesticated) animals, trade and travel, and sex and drug use. It includes the double-edged sword of medical technology that extends lives but also creates populations of vulnerable, immuno-compromised people. It includes anthropogenic changes to landscapes. We are becoming increasingly aware that habitat destruction brings with it the risk of zoonoses: when human and animal populations come into contact, diseases can spill over from the latter into the former. Lastly, it includes the complex interaction between climatic changes and disease.

The second framework is a temporal one. Frøland recognizes five transitions in human history where conditions and opportunities for microbes changed drastically, many of which are related to the above interactions. To wit: agriculture and animal domestication, the Columbian Exchange when European colonisers landed in the Americas, the Industrial Revolution during which sanitary conditions and hygiene standards improved, the discovery of bacteria in the 19th century, and the rapidly increasing globalisation after World War II. He is more upbeat than Jared Diamond who called agriculture our biggest mistake. Sure, Frøland writes, health initially took a hit, but it laid the grounds for later improvements that have more than compensated for this. He also singles out the influential ideas of social scientist Thomas McKeown who has argued that improved nutrition was the key factor behind increased lifespan, rather than breakthroughs in our medical and bacteriological understanding. Though several valid objections to this have been raised over time, the idea still pops up in popular discourse, e.g. when people question what medicine and vaccines have ever done for us.

With these two frameworks introduced, and after briefing the reader on the basics of microbiology, immunology, infection biology, and population genetics, Frøland turns to his history of infectious diseases. A stonkingly large chapter 4 that sprawls over 225 pages discusses the famous epidemics and pandemics of the past: bubonic plague, smallpox, typhus, cholera, measles, yellow fever, syphilis, tuberculosis, leprosy, malaria, influenza, and polio. An additional historical chapter deals with the mystery epidemics of the past where we still have no good idea of the pathogenic cause. A third chapter deals with the challenge of emerging infectious diseases: Ebola, HIV, SARS, Zika, and many others besides. Given that this book was originally written before the COVID-19 pandemic took off, that section will have been added in translation and is necessarily somewhat cursory and already outdated on some points. What was striking is that Frøland mentions influenza as the most likely next pandemic, even though many virologists, writers, and the World Health Organisation have prominently worried about coronaviruses.

These chapters are very informative and nicely combine epidemiological and historical details. Next to macro-historical patterns of how certain diseases spread and where they might have originated, Frøland ties them to the above-mentioned frameworks of ecological interactions and the five microbial transitions. Repeatedly, he shows how pathogens took advantage of humans rearranging the world around them. Furthermore, he mentions (famous) victims; a long list of notable syphilis sufferers is presented, for example. Fortunately, he avoids speculative historical counterfactuals (i.e. “if disease X had not broken out, would event Y still have happened?) Though interesting, he does not consider them a terribly useful way of studying history.

This same level-headed, measured approach characterises the rest of the book, which tackles a plethora of related topics. Frøland takes a good look at the possibility of diseases leading to the fall of empires. While admitting that such collapses were complex and multifactorial—it is never just one thing—he does think that we downplay the importance of infectious diseases. Next to historical curiosities, understanding these processes will hold important lessons for the future. He discusses a long list of countermeasures, everything from human behaviour to vaccines, antibiotics, drugs, and therapies. And there is an equally in-depth discussion of future challenges, everything from antibiotic resistance to the dangers of gain-of-function experiments in biomedical research and the possible effects of climate change.

Furthermore, Frøland avoids the Big Man narratives that you often encounter in popular representations of scientific discovery. We celebrate Louis Pasteur and Robert Koch for their microbiological discoveries while forgetting all the others on whose work they built. He questions the mythology around Lady Mary Wortley Montagu and Richard Jenner in the history of vaccines, and the apocryphal story of how Alexander Fleming discovered penicillin. Furthermore, Frøland is measured regarding what we do and do not know about, for instance, the microbial cause of chronic diseases or the actual threat of zombie viruses waking up as the world’s permafrost melts. And he shows a welcome degree of moderateness when discussing the balance between anti-epidemic measures and the costs to societies and individuals. As a medical doctor, he is less strident than you might expect when considering the very serious issue of vaccine hesitancy, and whether coercive measures are a good way of dealing with this.

As usual with Reaktion Books, the book is richly illustrated. I admit that I did not find the writing as captivating as some other books on this topic, but there is so much interesting historical material here that the book grips you in its own way. Overall then, Duel Without End is a broad, all-round introduction to the history of epidemics and pandemics that favours level-headed discussion over hyperbole.