Book Title: Pandemics, Poverty, and Politics: Decoding the Social and Political Drivers of Pandemics From Plague to COVID-19
Author: Tyler B. Evans, MD, MS, MPH
Publication Details: Johns Hopkins University Press, 2025, 496 pp., $39.95 paperback
This book discusses social determinants of health (SDoH) in the context of pandemics. The author is the right person for this job. The prologue summarizes his rise from poverty to global leadership in infectious diseases and chief medical officer of New York City during COVID-19. Packed with firsthand stories (anecdotes are more powerful than data for most people), the volume is economical but well-illustrated.
The first section begins with a primer on health systems. The review of models employed—Beveridge, Bismarck, national health insurance, and out-of-pocket—is quite useful. The critique of the US health care system comments on its fragmented, market-based approach, though perhaps the issue is less about markets per se than power differentials as the population is trampled underfoot of government and industries.
Excluding certain communities from quality-based health care does not mean that they will not access it. What it does mean is that they will not access it well. (Introduction, p. 4)
Differentiation of community health, public health, and population health sets the stage for the rest of the book. The importance of these became quite clear during COVID.
[Docs were] looking for someone to intubate. Instead, we needed community health workers, social workers, and mental health professionals who had the trust and faith of the communities at risk. We needed to navigate access. (Introduction, p. 6)
The next chapter identifies SDoH: economic, educational, access to quality care, and local community context. Political determinants of health are included.
[Political determinants] serve as instigators of the SDoH with which many people are already acquainted. (p. 79)
In pure form, the political process is the means by which groups having differing values or priorities work together to reach mutually acceptable solutions. In contemporary usage, it is associated with partisan ideologues and struggle for power. The former contributes to good health; the latter, to ill. During pandemics, partisanship yields distrust. Public health measures become perceived as done to, rather than for, the individual or their community. Imposed mandates may push populations toward laissez-faire politicians whose policies may blunt public health efforts.1
Recognizing SDoH, strategies for improving health take on a different hue. In some situations, the goal becomes harm reduction rather than acute cure, without abandoning efforts toward ultimate harm elimination. The goal involves acknowledging the adverse impact of SDoH—the injuries suffered—and neither blaming nor making out to be helpless victims; rather, empowering people. The goal recognizes that as population stress from poverty, overcrowding, and oppression builds, vulnerability increases. The World Health Organization defines health as more than merely the absence of disease; this perspective is clearly communicated.
The second section of the book presents syndemics: “cascading impacts of poverty and pandemics.” Terminology is well-defined, followed by an interactive review of pandemics in the 20th century. Worksheets present rubrics for assessing diseases’ sociopolitical determinants. Unfortunately, any discussion of smallpox was omitted. Similarly, discussion of political missteps requiring transfer of COVID-19 patients into nursing homes or effects of other pandemic responses on SDoH were absent.2,3,4 The section closes with an overview of current major infectious killers.
The final section offers a way forward. A comprehensive, rather than purely biological, view of syndemics is critical. Multidisciplinary teams incorporating SDoH into clinical care encounters build resiliency and reduce risk for the next pandemic. Focus on clinical and public health infrastructure and workforce is essential. The key is effective leadership, coherent and collective strategies, and trusted messengers.
An overall laudable contribution, portions of the book could be improved. A stated goal is depoliticizing public health. One assumes this means making it nonpartisan; public health is inherently political. However, depoliticizing is not entirely successful. The author favors Alinsky and ACT UP but is less tolerant of other directions of dissent. For example, when engaging faith communities, the emphasis is using them to parrot the experts’ messaging rather than learning their concerns and together developing a compromise: a valid harm reduction strategy.1 The use of “cultural competence” rather than the less presumptive “cultural humility” was disappointing. These symptoms of a coastal urban cultural bias might have been alleviated by collaborating with a coauthor with a different perspective and may have led to a more objective tone, strengthening the message of the book. Perhaps in the second edition.
Dr Evans’ book is a valuable addition to the library of family medicine educators. Its historical perspective and call to action are relevant and timely contributions to the literature on both pandemics and SDoH.
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