How We Can All Share the Fight Against Infectious Disease

By Frederick M. Cohan, Professor, Wesleyan University Department of Biology and College of the Environment

Not that long ago, Americans were confident that we would soon win the war against infectious disease. This confidence was spurred through most of the 20th century by extremely effective technologies that promised to eradicate infections. By the early century, the developed world was conquering the waterborne diseases that had plagued cities for thousands of years. The solution was simple—chlorinating public water prevented the germs from one person’s feces from entering another’s drinking water. By mid-century, the newly discovered wide-spectrum antibiotics were taming and treating all the bacterial pathogens that had infected our species since the onset of civilization. And by the 1960s, new vaccines were preventing the deadly viral diseases that had routinely plagued children for hundreds to thousands of years. Some public health officials wondered whether we might be approaching a world beyond pestilence (Spellberg and Taylor-Blake 2013).

The outlook for a world free of pathogens does not look so rosy now. While most (but not all) water supplies in the US remain secure (Stokdyk et al. 2019), the other two pillars of 20th century public health are running down everywhere. Bacteria are evolving resistance to antibiotics, such that tens of thousands of Americans are dying every year from bacterial infections that were controllable only decades ago (CDC 2013). And Measles is back, not from a failure of technology, but from a failure of parents to vaccinate their children, as seen in the recent outbreaks in Hartford and New York City (Stewart 2019, Zadrozny 2019)and elsewhere (Akbar 2019). The medieval plagues of Tuberculosis and Typhus are back on the rise, owing to neglect of the poor, both in our country and abroad (Pai 2019). Finally, some extremely dangerous infectious diseases are spilling over from other species, with the potential to kill many millions worldwide. Recent Ebola epidemics have gotten the most attention, but in recent decades many potentially lethal infections have entered humanity from wild and domestic animals, and have spread to at least hundreds and in some cases thousands to millions of people. The most notable of these spillovers is HIV, which entered our species from chimpanzees through bushmeat hunting a century ago, and has killed tens of millions of people in the last 40 years (Gao et al. 1999).

How will we fight the war against emerging and reemerging pathogens into the future? One way is through new technologies. In recent years, antimicrobial therapies have appeared for pathogens that were once recalcitrant to treatment (Chan et al. 2016); candidate vaccines are being developed for Ebola and a number of other diseases (WHO 2019a); and some tropical diseases may soon be controlled by genetic engineering approaches to kill their insect vectors (Flores and O'Neill 2018). This will all happen without any help from most of us, provided we continue to generously direct our tax dollars to public health. But here I want to focus on what we can all do to fight pathogens through changes in our behavior and attitudes toward infection. Some very simple changes in attitudes have powered our battles against infections in the past, and I will argue will likely do so again.

Of all scientific breakthroughs to affect the way we think and live, perhaps the Germ Theory of Disease has had the greatest impact on our everyday habits (Tomes 1998). The Germ Theory, developed in the late 19th century, states that epidemics are caused by microbes and that their transmission can be contained. Acceptance of the theory led to the realization that we could all take some responsibility for our own health and the health of others.

Here I aim to discuss some basic ideas that emerged early in the age of Germ Theory, and how these ideas can be updated to accommodate new knowledge about the emergence of infectious diseases. I’ll start with the most basic tenet of this behavioral revolution, that we all must take responsibility for keeping our germs to ourselves. I’ll then move to other impacts of the Germ Theory, including the responsibility to keep ourselves from getting infected and the benefits of caring for others who are infected. Finally, I’ll discuss recent discoveries that caring for the environment will help keep all of us free of infections.

Keeping our germs to ourselves. The Germ Theory quickly brought a new social contract[1]that we must all keep our germs to ourselves. In the late 19th century, before germs were appreciated as responsible for our illnesses, street vendors would routinely spit on their handkerchiefs to polish their apples for sale. Spit-polishing was normal and tolerated before ordinary people realized that saliva could transmit deadly pathogens (including tuberculosis). However, with widespread acceptance of the Germ Theory, the general public came to view spitting on others’ food as disgusting and dangerous, and street vendors were forced to adapt (Tomes 1998).

Over the last century, this basic idea has been extended in so many ways. Among the smallest is the gesture of containing a surprise sneeze with our upper sleeve (and not our hands). Among the largest is a public commitment to keep each person’s fecal germs from being drunk by others, through chlorinating every public water supply in the country. This universal buy-in to secure water supplies, motivated by the Germ Theory, became one of the 20th century’s pillars of public health.

Keeping our germs to ourselves has become part of the social contract for food handlers, codified in health laws and restaurant guidelines. This is because it is just too easy for one restaurant worker with mild diarrhea (mild enough to go to work) to pass their pathogens to restaurant patrons if hands are not washed. Restaurant workers are inculcated in the importance of washing their hands after using the toilet, or whenever they have touched something that might have germs (Bernal 2019). Those who violate the health code know they will be reprimanded, but the social contract is further enforced when management can promote a buy-in by employees by asking, “How would you feel if you went into a restaurant, and you saw your food handler touch his face before touching your food?” This can be more effective than expecting your employees to simply obey a set of rules.

The Japanese have taken the ethic of containing their germs to an unparalleled level. In Japan, it is disrespectful to spread disease to others, and so an open sneeze or cough is considered extremely bad etiquette (Phanthanh 2018). Hence, nearly all Japanese don a face mask during the cold and flu season. Not wearing a face mask is breaking a social contract, much like spit-polishing your apples.

It is important to note that face masks are highly effective not just in preventing a sick person from transmitting their germs, but also in protecting an uninfected wearer from getting sick (MacIntyre et al. 2009). Not getting sick in the first place is the most effective way to prevent ourselves from spreading germs, so aiming to keep ourselves healthy (to the extent that is reasonable) has become another component of the social contract stemming from the Germ Theory.

Keeping ourselves healthy. For over a century the Germ Theory has taught us that a person cannot get an infectious disease if there is no one in their neighborhood with the infection. This idea yields both a selfish and communitarian motivation for keeping people free of infections. Each individual has the selfish and obvious reason to avoid their own suffering, while the community has the motivation to keep each person healthy so that they won’t transmit an infection to others.

For many infections we have only limited ability to keep ourselves free of disease. We are not yet able to protect ourselves from the common cold or from most infections we get from animals (such as West Nile Virus and Lyme Disease) or from many tropical diseases, but in the temperate zone we can protect ourselves from most serious infections through vaccination.

Public investment in vaccine technology has led to fabulous victories over many pathogens that had attacked every generation (usually as children) for centuries and in some cases for millennia. For example, before Measles vaccination began in the 1960s, Measles was a dangerous yet inevitable rite of childhood, but vaccination entirely eradicated this disease from the US in just three decades. In the 1950s, Polio was a scourge yielding 15,000 cases of paralysis yearly in the US, but vaccines soon eradicated this disease from the entire New World (Fujimura 2005). The most heroic venture against infection was the global eradication of Smallpox, ending in the late 1970s (Fenner 1982).

These successes were possible because parents were eager in mid- 20th century to protect their children from diseases that had long plagued civilization. Parents who had suffered the extremely dangerous and painful Measles, Mumps, and Chickenpox were not likely to let their children suffer when there were efficacious and safe preventatives.

Most parents may not have realized it at the time, but vaccinating one’s own kids benefited not just those who were vaccinated, but also the entire community. A special kind of protection called “herd immunity” results when enough of the population is vaccinated. With herd immunity, an outbreak will not spread because nearly everyone an infected person might contact has been immunized. Herd immunity is life-saving because there are some people who cannot be vaccinated, such as newborns and those with suppressed immune systems. Moreover, because the vaccines are inevitably not 100% effective, herd immunity also protects the rare individual who has been vaccinated but is not immune. Thus, every one of us contributes to others’ health by immunizing ourselves (or our children) against infectious diseases.

When the childhood diseases were still common, the motivation for protecting one’s own family from infections was urgently driving our behavior. That is, if you didn’t vaccinate your kids, they would surely suffer from some nasty diseases that beyond bringing discomfort, could yield lifetime harm. Now that Measles is rare (at least in most communities), any risk from vaccination (even if nearly zero) becomes more important in our decisions.

Recent propaganda by the anti-vaxxer movement has exaggerated the near-zero risk from vaccination to the point that the risk becomes, for many, more important than the potential benefit of vaccinating against diseases. The recent anti-vaxxer campaigns began with a study at the turn of the millennium that purported to show that the MMR vaccine (against Measles, Mumps, and Rubella) causes autism. This study was soon shown to be not just false but deliberately fraudulent, and much effort has gone into debunking the myth that vaccination causes autism, yet thanks to social media, the myth just won’t die. I’ll add that a very recent Danish study, following hundreds of thousands of children over decades, has definitively shown that MMR does not lead to autism (Hviid et al. 2019). It just doesn’t happen!

Why won’t the myth die? It is much more than fear of autism. Concerns about vaccines more generally stem from a distrust of scientists, who anti-vaxxers believe are hiding the risks of vaccines, or a distrust of pharmaceutical companies, who are always hawking meds at us on television, or a distrust of government, who anti-vaxxers believe is encroaching on their personal liberties. (Hoffman et al. 2019). It is important when discussing the public health importance of vaccines to understand the diversity of concerns anti-vaxxers have, and we all need to understand that it is easy to subscribe to conspiracy theories about vaccines when the diseases they prevent are not imminent. Perhaps the most important point to be communicated is that the failure to vaccinate is bringing Measles to the cusp of becoming imminent once again in all our communities (Ragotte 2019). With Measles emerging in dozens of regions around the country and around the world, we need to understand that an unvaccinated population is like a tinderbox with a nearby child throwing lighted matches. Indeed, the World Health Organization has rated vaccine hesitancy as one of the top ten threats to public health (WHO 2019b). Fortunately, in the last year social media posts favoring vaccination have become more prevalent than anti-vax posts (Menczer and Hui 2019).

Owing to the growing imminence of epidemic Measles, those who do not vaccinate their kids are now seen as pariahs. That is, these parents are breaking a social contract to protect public health by keeping themselves and their families healthy when they can. This is seen in the recent Measles outbreaks in New York State, where the health authorities of Rockland County have prohibited unvaccinated children from public spaces (recently overturned (AP 2019)), and the mayor of New York City is requiring everyone in parts of Brooklyn to show proof of vaccination (Pager and Mays 2019).

Ostracizing unvaccinated individuals in New York has expanded to shunning the local community of Orthodox Jews, who are known to reject vaccination (Nir and Gold 2019). When the fear of infection is palpable, we become as disgusted by vaccine hesitancy as were our forebears when they saw street vendors spit-polishing their apples. The Germ Theory has now brought us to a social contract where we are expected not just to keep our germs to ourselves but also to keep ourselves healthy when we reasonably can.

Socialism of the Microbe. A concept dubbed the “Socialism of the Microbe” emerged soon into the Germ Theory era. This was the idea that we must work to prevent and treat infections in others, lest others’ infections become our own (Edson 1895). One consequence was organized labor’s efforts to fight tuberculosis at the turn of the 20th century (Tomes 1998, Hoffman 2003). Public health workers realized that those most likely to become infected received low wages and lived in crowded tenements with insufficient food. With the aim of bolstering the safety of everyone, both rich and poor, from TB, the Progressive Era brought economic reforms, including minimum wage legislation and prohibitions against child labor. These reforms are credited with halving the rate of mortality from TB in New York City in the first two decades of the 20th century, all before effective drug therapy (Hermans et al. 2015). Reforms through the New Deal further helped reduce abject poverty, as well as tuberculosis.

With the ascendancy of neoliberalism since the election of Ronald Reagan, there has been much less interest in treating poverty or the infections associated with poverty, or in social investment more generally. What emerged in the 1980s and beyond was the conviction that many who were poor or sick with infectious disease had largely themselves to blame. In the US, national and state governments became less interested in reducing poverty, and paid less attention to how poverty led directly to some infectious diseases, particularly tuberculosis and AIDS (Hacker and Pierson 2016). One consequence is that homeless populations are increasing in the US, now numbering half a million, and they are experiencing outbreaks of TB as well as Typhus, owing to limited access to health care, an abundance of rats, and crowded living conditions (Gorman 2019).

This is an auspicious time to apply the Socialism of the Microbe to tuberculosis. In recent years, rapid diagnosis of TB has been developed, so treatment can begin right away, and combination drug treatments can quickly and reliably cure cases of TB (Goosby et al. 2018). In addition, preventative antibiotic therapy has been shown effective for those who have been in contact with TB but do not yet show symptoms (Saunders and Evans 2019). As a result, we now have the technological means to break the cycle of infection, but what is lacking, both in our country and in the poorest countries where TB is ascendant, is universal access to health care (Goosby et al. 2018).

Likewise, the technology for combatting HIV/AIDS has reached a promising point. We can now readily diagnose the disease, even in patients who are not yet experiencing AIDS symptoms. This is important because most HIV transmission is from people who are not yet aware they are infected (Li et al. 2018). Also, extremely effective “cocktails” of multiple antiretroviral therapies are now capable of reducing HIV to undetectable levels. Fortunately, when HIV is reduced to that extent, it appears not to be transmissible (McCray 2017). Consequently, the WHO and the American CDC share the ambition to globally eradicate HIV in the coming decades (Brown et al. 2018). The obstacles to reaching this goal are not technological—the challenge is to find the political will and the money to reach all who are infected, diagnose them, and treat them. This goal is a Socialism of the Microbe writ large—by preventing HIV in those we don’t even know, we protect ourselves and our families from ever contracting the disease.

Extending the Socialism of the Microbe abroad. If the Socialism of the Microbe is to eradicate TB and HIV, even if only within our own country, the struggle must extend beyond our borders. The world is just too small to expect that a socialistic approach directed only to our own citizens could protect us from infection.

The US in recent years ramped up its commitment to fight infectious disease abroad, particularly in developing countries. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria was created during the George W. Bush administration as an international and private/public sector collaboration, and was expanded under Barack Obama. This program has treated 1.5 million people with TB and has provided 5.5 million people with antiretroviral therapy, and has effectively reduced infections abroad and in our country (Hart 2019). Nevertheless, our country’s commitment to fighting infectious disease abroad has declined substantially under Donald Trump’s administration. Trump has cut funding to the Global Fund by a third, which will result in hundreds of thousands fewer people receiving antiretroviral therapy (Herrick 2019).

The Socialism of the Microbe can also extend toward helping the billion people around the world who lack a secure water supply. Water-borne disease is a perennial threat to health for much of the developing world—without a secure water supply, people routinely suffer from drinking the germs in other people’s feces. As a result, 80% of illness and death in the developing world is caused by water-borne infections (Batterman et al. 2009). Creating sustainable water sources, free of pathogens, is a top priority for developing the health and economic productivity of people in developing countries.

Beyond benefiting the livelihoods of a billion people, an American commitment to securing water in the developing world would be a socialistic sacrifice with payback for better health in our own country. The problem is that treatment of diarrheal disease throughout the developing world has required a huge consumption of antibiotics. This has contributed to increases in antibiotic resistance in developing countries, and resistant pathogens have then moved across continents and oceans to threaten the fight against bacterial diseases everywhere (Nordmann et al. 2011). International investment in secure water supplies would reap health benefits for the entire world by obviating enormous consumption of antibiotics for diarrheal disease (Klein et al. 2018).

Finally, extending the Socialism of the Microbe internationally could help to contain extremely dangerous pathogens that spill over from wild animals into human populations. Most notably, Ebola has emerged over a dozen times in West and Central Africa in the last several decades, and the last two outbreaks in West and Central Africa have infected and killed thousands of people. In these outbreaks, humans have become infected from fruit bats, where Ebola virus circulates in high frequency (Hayman et al. 2012). The incidence of spillover events from bats to humans will only increase into the future as a result of deforstation and human incursions into the forest, for example to hunt bats for food (Wallace et al. 2016). Moreover, with increasing transportation in and out of rural villages, the likelihood of an Ebola (or any other spillover) infection spreading internationally will increase.

A 21st century Socialism of the Microbe would protect Americans from Ebola by investing in the public health infrastructure of sub-Saharan Africa. Where the West African epidemic began, in the small town of Meliandou in Guinea, there were no Ebola clinics in the country, and the disease quickly spread into neighboring countries, as well as the US and Europe. By the time the disease was contained, after much international investment, there had been over 27,000 cases and over 11,000 deaths.

A better approach would involve having a public health infrastructure already in place throughout the regions at risk for Ebola. Then clinics would immediately be able to administer palliative care, as well as various recently developed monoclonal antibody treatments (Pascal et al. 2018). Also, if clinics were armed with the newly developed rVSV-ZEBOV vaccine, they would be able to contain the virus with a “ring” approach to vaccinating villages that surround a known outbreak (Gostin 2018). International help from developed countries will constitute a rejuvenated Socialism of the Microbe that will protect the entire world from emerging pathogens plaguing us now and into the future.

Environmental protection and infection. One final way we can all fight infection is through protecting the environment. It turns out that every way humans have damaged the environment has come back to kill us through infectious disease (Cohan and Klimasmith 2018). Whether it’s destroying forests, hunting wild animals, travel and transport of wild creatures, or climate change, each of these assaults on nature has brought us infections. For example, with global warming most species of animals and plants are moving away from the equator toward cooler habitats, and the insect vectors of infectious diseases are no exception.

As the tropics become too hot for either humans or the insects that transmit diseases to us (Ryan et al. 2019), vector-borne infectious diseases are inching their way from the American tropics into the US. One particularly frightening tropical disease is already here! Leishmaniasis is found throughout the tropics and severely disfigures the skin, sometimes horribly scarring the victims’ faces. Leishmania parasites are maintained in wild rodents and are transmitted by sandflies, and both the rodents and sandflies are expected to move poleward as the world warms (Gonzalez et al. 2010). Leishmaniasis was until the turn of the 20th century never seen north of the US-Mexican border, but throughout the 20th century it has moved northward across Texas and in this century into Oklahoma, (Clarke et al. 2013)and even North Dakota (Douvoyiannis et al. 2014). There is much to fear from human-caused climate change, from deadly heat waves to rising sea levels and superstorms, but perhaps the prospect of acquiring very nasty tropical diseases may motivate a bipartisan fight against global warming.

Technologies have brought us a long way since we first discovered that infectious diseases are caused by germs, so it is tempting to just wait for the next invention to save us from present and emerging plagues. But there is much we can all do, even with existing technology, to save both ourselves and strangers from infection. The key is that we must each take responsibility for keeping our germs to ourselves, keeping ourselves healthy, investing in the health of strangers, and protecting against environmental disturbances. While new technologies will surely help the fight against infection, each new discovery will be so much more effective when there is an infrastructure of public commitment to containing infection.

Bibliography

Akbar, R. 2019. Ten threats to global health in 2019.inWHO, editor.

AP. 2019. Court halts New York county’s anti-measles emergency order. Associated Press.

Batterman, S., J. Eisenberg, R. Hardin, M. E. Kruk, M. C. Lemos, A. M. Michalak, B. Mukherjee, E. Renne, H. Stein, C. Watkins, and M. L. Wilson. 2009. Sustainable control of water-related infectious diseases: a review and proposal for interdisciplinary health-based systems research. Environ Health Perspect 117:1023-1032.

Bernal, J. 2019.

Brown, A. E., R. Hayes, T. Noori, Y. Azad, A. J. Amato-Gauci, A. Pharris, V. C. Delpech, and N. The Ecdc Dublin Declaration Monitoring. 2018. HIV in Europe and Central Asia: progress in 2018 towards meeting the UNAIDS 90-90-90 targets. Euro Surveill 23.

CDC. 2013. Antibiotic resistance threats in the United States, 2013.

Chan, B. K., K. Brown, K. E. Kortright, S. Mao, and P. E. Turner. 2016. Extending the lifetime of antibiotics: how can phage therapy help? Future Microbiol 11:1105-1107.

Clarke, C. F., K. K. Bradley, J. H. Wright, and J. Glowicz. 2013. Case report: Emergence of autochthonous cutaneous leishmaniasis in northeastern Texas and southeastern Oklahoma. Am J Trop Med Hyg 88:157-161.

Cohan, F., and I. Klimasmith. 2018. As the world warms, deadly and disfiguring tropical diseases are inching their way toward the U.S. Los Angeles Times.

Douvoyiannis, M., T. Khromachou, N. Byers, J. Hargreaves, and H. W. Murray. 2014. Cutaneous leishmaniasis in North Dakota. Clin Infect Dis 59:e73-75.

Edson, C. 1895. The microbe as a social leveller. The North American Review 161:421-426.

Fenner, F. 1982. A successful eradication campaign. Global eradication of smallpox. Rev Infect Dis 4:916-930.

Flores, H. A., and S. L. O'Neill. 2018. Controlling vector-borne diseases by releasing modified mosquitoes. Nat Rev Microbiol 16:508-518.

Fujimura, S. F. 2005. The man who made polio history. Perspectiveds in Health. Pan-American Health Organization

Gao, F., E. Bailes, D. L. Robertson, Y. Chen, C. M. Rodenburg, S. F. Michael, L. B. Cummins, L. O. Arthur, M. Peeters, G. M. Shaw, P. M. Sharp, and B. H. Hahn. 1999. Origin of HIV-1 in the chimpanzee Pan troglodytes troglodytes. Nature 397:436-441.

Gonzalez, C., O. Wang, S. E. Strutz, C. Gonzalez-Salazar, V. Sanchez-Cordero, and S. Sarkar. 2010. Climate change and risk of leishmaniasis in north america: predictions from ecological niche models of vector and reservoir species. PLoS Negl Trop Dis 4:e585.

Goosby, E., D. Jamison, S. Swaminathan, M. Reid, and E. Zuccala. 2018. The Lancet Commission on tuberculosis: building a tuberculosis-free world. Lancet 391:1132-1133.

Gorman, A. 2019. Medieval Diseases Are Infecting California’s Homeless. The Atlantic.

Gostin, L. O. 2018. New Ebola Outbreak in Africa Is a Major Test for the WHO. JAMA 320:125-126.

Hacker, J. S., and P. Pierson. 2016. American Amnesia: How the War on Government Led Us to Forget What Made America Prosper. Simon & Schuster, New York.

Hart, T. 2019. World Health Day: It's time to fight preventable disease. The Hill.

Hayman, D. T. S., M. Yu, G. Crameri, L.-F. Wang, R. Suu-Ire, J. L. N. Wood, and A. A. Cunningham. 2012. Ebola virus antibodies in fruit bats, Ghana, West Africa. Emerging Infectious Diseases 18:1207-1209.

Hermans, S., C. R. Horsburgh, Jr., and R. Wood. 2015. A Century of Tuberculosis Epidemiology in the Northern and Southern Hemisphere: The Differential Impact of Control Interventions. PLoS One 10:e0135179-e0135179.

Herrick, B. 2019. Trump Budget Proposes Largest Ever Cuts to Global HIV Programs. Health Gap.

Hoffman, B. 2003. Health care reform and social movements in the United States. Am J Public Health 93:75-85.

Hoffman, B. L., E. M. Felter, K. H. Chu, A. Shensa, C. Hermann, T. Wolynn, D. Williams, and B. A. Primack. 2019. It's not all about autism: The emerging landscape of anti-vaccination sentiment on Facebook. Vaccine 37:2216-2223.

Hviid, A., J. V. Hansen, M. Frisch, and M. Melbye. 2019. Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. Ann Intern Med.

Klein, E. Y., T. P. Van Boeckel, E. M. Martinez, S. Pant, S. Gandra, S. A. Levin, H. Goossens, and R. Laxminarayan. 2018. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proceedings of the National Academy of Sciences 115:E3463-E3470.

Li, Z., D. W. Purcell, S. L. Sansom, D. Hayes, and H. I. Hall. 2018. Vital Signs: HIV Transmission Along the Continuum of Care - United States, 2016. MMWR Morb Mortal Wkly Rep 68:267-272.

MacIntyre, C. R., S. Cauchemez, D. E. Dwyer, H. Seale, P. Cheung, G. Browne, M. Fasher, J. Wood, Z. Gao, R. Booy, and N. Ferguson. 2009. Face mask use and control of respiratory virus transmission in households. Emerg Infect Dis 15:233-241.

McCray, E. 2017. Information from CDC's Division of HIV/AIDS Prevention.inCDC, editor.

Menczer, R., and M. Hui. 2019. Anti-vaxxers appear to be losing ground in the online vaccine debate. The Conversation.

Nir, S. M., and M. Gold. 2019. An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism. New York Times.

Nordmann, P., T. Naas, and L. Poirel. 2011. Global spread of Carbapenemase-producing Enterobacteriaceae. Emerging Infectious Diseases 17:1791-1798.

Pager, T., and J. C. Mays. 2019. New York Declares Measles Emergency, Requiring Vaccinations in Parts of Brooklyn. New York Times.

Pai, M. 2019. A human-rights approach is essential to end the global TB epidemic. The Conversation.

Pascal, K. E., D. Dudgeon, J. C. Trefry, M. Anantpadma, Y. Sakurai, C. D. Murin, H. L. Turner, J. Fairhurst, M. Torres, A. Rafique, Y. Yan, A. Badithe, K. Yu, T. Potocky, S. L. Bixler, T. B. Chance, W. D. Pratt, F. D. Rossi, J. D. Shamblin, S. E. Wollen, J. M. Zelko, R. Carrion, Jr., G. Worwa, H. M. Staples, D. Burakov, R. Babb, G. Chen, J. Martin, T. T. Huang, K. Erlandson, M. S. Willis, K. Armstrong, T. M. Dreier, A. B. Ward, R. A. Davey, M. L. M. Pitt, L. Lipsich, P. Mason, W. Olson, N. Stahl, and C. A. Kyratsous. 2018. Development of Clinical-Stage Human Monoclonal Antibodies That Treat Advanced Ebola Virus Disease in Nonhuman Primates. J Infect Dis 218:S612-S626.

Phanthanh, C. 2018. Why Japanese wear masks: a look behind health, etiquette, and culture. Go! Go! Nihon.

Ragotte, R. 2019. Vaccination is part of the social contract. Somehow, we’ve lost sight of that. Globe and Mail.

Ryan, S. J., C. J. Carlson, E. A. Mordecai, and L. R. Johnson. 2019. Global expansion and redistribution of Aedes-borne virus transmission risk with climate change. PLoS Neglected Tropical Diseases 13:e0007213.

Saunders, M. J., and C. A. Evans. 2019. Ending Tuberculosis through Prevention. New England Journal of Medicine 380:1073-1074.

Spellberg, B., and B. Taylor-Blake. 2013. On the exoneration of Dr. William H. Stewart: debunking an urban legend. Infectious Diseases of Poverty 2:3-3.

Stewart, D. 2019. 3rd case of measles reported in state; case tied to ones in NY. Fox 61.

Stokdyk, J. P., S. K. Spencer, J. F. Walsh, J. R. de Lambert, A. D. Firnstahl, A. C. Anderson, L. W. Rezania, and M. A. Borchardt. 2019. Cryptosporidium Incidence and Surface Water Influence of Groundwater Supplying Public Water Systems in Minnesota, USA. Environ Sci Technol.

Tomes, N. 1998. The Gospel of Germs: Men, Women, and the Microbe in American Life. Harvard University Press, Cambridge, Mass.

Wallace, R. G., R. Kock, L. Bergmann, M. Gilbert, L. Hogerwerf, C. Pittiglio, R. Mattioli, and R. Wallace. 2016. Did Neoliberalizing West African Forests Produce a New Niche for Ebola? Int J Health Serv 46:149-165.

WHO. 2019a. Immunization, Vaccines and Biologicals.

WHO. 2019b. Ten threats to global health in 2019. Emergencies. WHO.

Zadrozny, B. 2019. Brooklyn measles outbreak: How a glossy booklet spread anti-vaccine messages in Orthodox Jewish communities. NBC News.

_______________________________________________________________________________________

[1]I will use “social contract” to mean a common understanding of the sacrifices we are all expected to make for the common good.