Crisis Averted: The Hidden Science of Fighting Outbreaks

by Caitlin Rivers

A fascinating window into the secret life of epidemiology, weaving together stories of triumph and tragedy, with a boots-on-the-ground perspective on how we can avert the next public health crisisThere are few visible markers of the accomplishments of public health. If epidemiologists do their jobs, nothing happens. An outbreak does not grow into an epidemic. A child does not go hungry. A would-be smoker never lights up. These achievements are rarely noticed or celebrated, but Caitlin Rivers lives for such victories. By making sure that things don’t happen, she and legions of scientists, practitioners, and policymakers change the course of history.We have many of the tools and experiences needed to prevent the next crisis, but countless challenges remain, including constantly emerging pathogens, the rapid growth of biotechnology, and the inconsistent cycles of funding for government organizations like the CDC. Progress can be slow, even with the next pandemic potentially right around the corner, but the unsung heroes in public health remain focused on their missions. Averted is their story—from the eradication of smallpox in the 20th century to today’s safeguards against extraterrestrial germs.  By taking a candid look at how we solve problems in public health, Caitlin Rivers illuminates the role of epidemiology in all our lives and lays out the case for what can be accomplished, given sufficient vision, leadership, and resources. Averted is an inspiring and galvanizing clarion call for us to work together towards a healthier, more resilient future.

Genres: Science, Nonfiction, Audiobook, History, Medical, Health, Medicine

320 pages, Hardcover

Published October 8, 2024

Reviews

[Tori · Rating 4 out of 5]

This was really accessible to me, as someone who really doesn't know a lot of science or epidemiology. I definitely learned a lot from it (like anthrax is a bacteria, not a poison lol), and I appreciate Rivers's perspective regarding the fine line public health experts need to walk.

So it's a good book, I feel like I came away from it having learned a lot. That said, and with the understanding that one book can't do everything, I felt the lack of a sociological lens, especially regarding the way public health needs to navigate things like the anti-vax movement. Those things simply don't happen in a vacuum.

While I'm sympathetic to the fact that the author likely wants to appeal to anti-vax and other conservative readers by sympathizing with them, it felt like a real gap in the narrative. While I'm interested to learn in the substantial work George W Bush did surrounding HIV/AIDS in Africa, it also feels negligent to skip over the way the AIDS crisis was mishandled in America.

The author does touch on the sociological aspect in the conclusion, but they would have been more impactful had been dispersed throughout the entire book. I also keenly felt the absence of an anti-capitalism perspective in the book, which felt borderline irresponsible given the way the author talks about the impact lobbying, and lack of funding impact public health.

All of that said, this was very interesting, very informative, and I enjoyed listening to the audio book.

[Hailey · Rating 5 out of 5]

disclaimer: i’m an epidemiologist. if you’re not, i want you to read this book! it’s accessible and engaging with a really wide range of interesting case studies (some new to me, some deeply familiar!) dr. rivers is an amazing communicator.

i still don’t know exactly “where we go” from here as public health professionals - seeing how the public reacted to covid-19 scares me, but i think that this book offers a lot of good, balanced information that would help people understand the field, our goals, and our tools! it feels honest - public health doesn’t always get it right - and reflective in a way that i think can help build back trust without sounding preachy. the case studies selected are genuinely fun — space diseases DO make an appearance!

i know there will be selection bias and that this book will probably mostly be read by people from a more liberal background or in the public health field already, but i hope it spreads beyond. for those who like to do their own research — start here! this book touches so many topics in a short amount of time, and there’s something to learn for everyone.

[Debbie Mitchell · Rating 5 out of 5]

This book is an accessible discussion of the history and science of epidemiology.

I really loved when the author described in detail how an epidemiologist approaches an outbreak to determine the mode of transmission, the impact of the virus, and the source of the virus.

There was a lot of interesting history in this book like the eradication of small pox, the importance of biosafety levels, Balto and the diphtheria outbreak in Nome, AK, and I had no idea that George Bush worked to eradicate AIDS in Africa!

I really appreciated that the author talked about some of the mistakes around the COVID-19 pandemic, but I wanted more information! Especially the history of when and how scientists realized COVID is aerosolized. I was hoping she would have talked about CO2 sensors and different types of masks & air purification with aerosols in mind.

Overall, very good and I’d definitely recommend!

(4.5 stars)

[Jeanne · Rating 4 out of 5]

Informative, engaging and scary as hell.

[Meg · Rating 5 out of 5]

Public health has always been an interest of mine - my grandfather was an MD, MPH and served in the Navy public health service. (For some cool family history: this meant my mother lived in Alaska for a bit as a child while my grandfather worked on lung diseases in indigenous populations; he also was a major part of the smoking study that directly linked smoking to lung cancer.) You also may know that I'm a fan of plague novels, which is truly less about the diseases themselves, but more about the ways communities respond to them.... hence public health!

When @onlyonebookshelf and @heydebigale recommended this for the January read for their Science Nonfiction book club, I knew I needed to pick it up. This book *did not disappoint*. I had every intention of reading it slowly, maybe a chapter at a time, and ended up listening to the entire audiobook in one sitting. Caitlin Rivers details the history and practical applications of public health through thematic chapters: Perserverance, Complacency, Skills, Foundations, Truth Telling, Politics, Commitments, Surprised, Technologies, Mysteries, and Progress. The delicate nature of public health is that it is the underfunded yet crucial backbone to a functioning healthy society. The strong central thesis to this book is to educate on the history and the role of public health officials and showcase the array of diseases and infections that public health plays a major role in.

[K. · Rating 4 out of 5]

Content warnings: pandemic, epidemic, mentions of terrorist attacks, problems during pregnancy, terminal illness

A compelling examination of disease and the ways in which society both fights back against it and prepares for its inevitable arrival. This was, a lot of the time, extremely US-centric and I wish it had looked more broadly at the approaches of other countries. Also I'm probably now on a watchlist of some description because the section on anthrax had me wondering what Australia's reaction would be (the federal government has a plan. It's from 2012 lol).

All in all, this was good but at the same time I wish I'd read it with my eyeballs and not my ears because there were chunks of this that just sailed straight past my brain and out the other ear.

[Aubrey Daly · Rating 5 out of 5]

I loved this book, Caitlin Rivers did an excellent job illustrating the complexities of public health and outbreak prevention. In order to succeed in the next pandemic we must learn from Public Health history and use the lessons learned to inform us moving forward. Caitlin wrote in a way that was very easy to follow and very informational, I truly think it would be beneficial for everyone to read this.

[Jillian · Rating 5 out of 5]

I loved this book! Found it very accessible to the general public

[Maya · Rating 3 out of 5]

Good introduction to epi for those new to public health.

[Nicole Reads Romance · Rating 4 out of 5]

This was a very informative, and accessible read. I did zone out on a few of the very America-centric bits (like when none of the acronyms wanted responsibility). I learned some interesting tidbits, some science-y and some about things like the Iditarod. I wish I’d eyeballed this for annotating instead of reading via audio.

[Andy · Rating 3 out of 5]

Given the title, I was expecting some cutting edge insights on stopping outbreaks, but the content was mainly historical and conventional. The book works okay as a sort of intro to infectious disease epidemiology, but that isn't what I was looking for.
The author makes a good case for the idea that public health victories are often forgotten, so people get lackadaisical and then the problems come back. This is true, but not a new or "hidden" idea.

Alternatives:
Microbe Hunters
Investigating Disease Patterns: The Science of Epidemiology
Rats, Lice, and History: A Chronicle of Pestilence and Plagues
The Origins of Human Disease


Nerd addendum:
The author is generally accurate in her digests of famous stories in epidemiology, but she gets some important details wrong. For example, when talking about COVID and SARS, she seems to mix up the death to infection ratio and the case fatality rate.

[Ann · Rating 2 out of 5]

The author characterizes public health as “medicine’s quieter cousin”, and points out that the successes of public health measures are invisible, the things that didn’t happen (the potential epidemic that was nipped in the bud, the children who were not exposed to second-hand smoke…). Her description of the cycle of panic and neglect was very apt: something bad happens - general panic ensues - many resources are freed up to combat it -things get better- resources are withdrawn again– until the next outbreak.

So the book represents both an education for the general public, as well as a plea not to neglect/underfund/deprioritize the invisible work that epidemiologists do. All of which I agree with. But I had been drawn to the book by its subtitle “the hidden science of fighting outbreaks”, and there was actually very little of that in the book. Yes, I did learn that there had been an adenovirus vaccine that was available only the US military (why?), and that its production had been allowed to lapse before it had to be restarted again, at great cost. And I did learn that the outbreak of cholera in Haiti lasted for about a decade and probably originated from an international rescue worker who had brought the bug from Nepal. And the chapter on the concerns about either introducing germs from earth into space, or importing space germs to earth, was interesting.

I had been looking forward to reading more about the anthrax investigation of 2001, or the mpox scare, or Ebola, or Zika, or Chikungunya, and how, exactly, the epidemiologists went about containing these outbreaks. But so much of this book felt like filler to me. To give just an example: in the 26-page chapter titled “Truth Telling”, which dealt with the tension between the desire to provide early warnings of a disaster that may or may not happen vs. the fear of causing a general panic, I counted 18 pages about tornado warnings and only a few about the early days of COVID.


Bottom line: this book’s subtitle should have been “what public health and epidemiology can do for you”, not “the hidden science of fighting outbreaks”.

[K · Rating 3 out of 5]

Fine, although somewhat pedestrian and not a lot of new ground covered.


p. 40 "Outbreaks, pandemics, eradication programs - these events have an intensity and urgency to them that bestows energy, purpose, a sense of missino. Public health officials get right to work bringing the situation under control, and they do so with widespread support. As their efforts begin to pay off, case counts diminish. Progress, though, is not triumph. The peak of the outbreak is the halfway point, not the finish line. As transmission slows, urgency fades. The funding and attention that powered the earlier efforts wane, and progress begins to unwind. Then it's back to the beginning, and the cycle begins again. Neglect has set in."

p. 158 The Rajneeshee plot "The upcoming election called for even more aggressive tactis. Ma Anand Sheela, one of Rajneesh's closest deputies, hatched a plot to tip the balance, this time not by stacking the vote but by suppressing voter turnout. Sheela dispatched adherents to restaurants and grocery stores around the region with tiny vials of bown slurry, which they sprinkled onto grocery store produce and buffet-style meals at area restaurants. The revolting mixture was salmonella, a bacterial pathogen that causes food poisoning symptoms like vomiting and diarrhea. Sheela had purchased the bacteria through a medical supplier and incubated it on the Rajneeshee compound. Her plan was to incapacitate voters to deter them from turning out. Her plan more or less worked. An estimated 751 people fell ill, and at least 45 were hospitalized, making it the largest deliberate outbreak in US history."

p. 206 "But the chronic form of encephalities lethargica was unique for how thoroughly it could incapacitate its victims. Although conscious, victims were catatonic, seemingly without cognition. As famously documented by author and neurologist Oliver Sacks in Awakenings, people stricken by the chronic form of encephalitis lethargica existed as if in suspended animation. Only with considerable prompting could they be convinced to move, eat, or participate in daily life."

[Sav · Rating 5 out of 5]

A modern summary of public health's successes and shortcomings. I'm sure this book would be quite basic to a public health expert but it's an accessible introduction that I appreciated even as a healthcare professional. While I thoroughly learned about the benefits of vaccines in pharmacy school, there was less emphasis on public health strategies as a whole. I think this book provides a great perspective that I will incorporate into my work and daily life.

I learned a great deal. I'm walking away with a clearer sense of how public health initiatives work, what obstacles they face, and their complicated relationship with politics. I also learned some new facts.

I learned that the first vaccines were delivered via jet injectors and that the precursor to the needles and syringes of the modern day were actually bifurcated needles. The bifurcated needle was invented by Benjamin Rubin when he ground down the eyelet of a sewing needle.

I learned that there is an oral adenovirus vaccine only available to the United States military. It was used from 1971 to 1999. Its effectiveness over that time period allowed complacency to set in, and when the manufacturer faced closure due to unacceptable conditions and lack of funding to rectify them, the US military did nothing until it was too late. This allowed adenovirus serotypes 4 and 7 to once again ravage training camps. They were only able to re-establish production of the vaccine again in 2011.

I learned a United Nations peacekeeper camp caused the massive cholera outbreak in Haiti in 2010. Haiti is still struggling to control the spread of cholera in 2024. The UN established a $400 million dollar trust fund as reparation for their actions but even today has raised only about $20 million dollars.

[Jaime Varela · Rating 4 out of 5]

Dr. Rivers highlights important biosecurity challenges that threaten global health today. The chapters on space germs, emerging technologies and mysterious epidemics were particularly interesting and thought-provoking. They illustrate just how challenging it is to identify an outbreak and stop disease transmission when there are many factors such as time and resource constraints, bureaucratic red tape, and public distrust working against you. The concluding chapter perfectly encapsulates the challenges and opportunities public health practitioners face in a post-pandemic society.

Biggest takeaway: “Effective communication is therefore the main challenge facing public health practitioners, and so the question becomes: How can we best convince people to adopt healthy practices? The solution requires a nuanced approach, one that relies on listening as much as telling.”

Biggest gap: Didn’t cover the role foreign adversaries play in undermining global health security. Particularly, how China’s actions of withholding critical information during the early months of the COVID-19 pandemic inhibited U.S. pandemic response efforts.

[Andrea · Rating 5 out of 5]

Excellent info, although reading this in the summer of 2025 is painful due to knowing how many of the vital programs described have been gutted or have an uncertain future. Global public health impacts all of us and it’s vital to continue funding programs in other countries.

My one quibble is that info on the efficacy of masking was ignored. Since 2020, B Yamagata flu has not been detected and it is believed to have gone extinct due to (inconsistent and erratic) pandemic mitigation efforts. If that was able to eliminate a strain of the flu, can you imagine how many circulating respiratory infections we could eradicate with a year or two of adequate global masking efforts? Can you imagine how many lives would be saved just with people masking while experiencing active symptoms? The amount of money saved on sick days alone would be incredible. Sadly, this is an unpopular view and I’m not surprised the author chose not to address it.

[James McAward · Rating 5 out of 5]

Super engaging, accessible, and overall fascinating look at the mostly-hidden world of public health… in the author’s words, “if we do our jobs right, nothing happens.” Well… lots happens all the time, and Dr. Rivers lays it down clearly and concisely. I read a
good deal of what I call “dystopian non-fiction”, and yet this book is anything but… instead it’s a clear-eyed look at the successes and failures of public health, its miserable subsistence funding, and most importantly, its critical role in helping us live our best lives… alive. If I was fortunate enough to be a Johns Hopkins student, I would definitely want to take her course, based only on this excellent book. Read this and you’ll have spent your time wisely.

[Chloe · Rating 5 out of 5]

I loved this book, in particular I loved how Rivers drew parallel from ancient and historical pandemics, modern day medicine and epidemiology, and various facets of society that contribute to public health. The book to me was an amazing narrative driven exploration of disease, society, and human behavior. I admire the concepts surrounding epidemiology, public health, and policy were demonstrated in historical examples rather than lengthy definitions or thought experiments. What makes a great scientific writer is the ability to communicate knowledgeable in a way that is not only understandable, but interesting and relevant to the average reader.

[Jen Womack · Rating 5 out of 5]

A most excellent book on how public health works from my favorite epidemiologist. If you haven’t read her blog, it’s a must! Can’t recommend this book enough and not just because I work in public health. This is a must read for any parent, citizen, or concerned adult. The author helps explain the inherent uncertainty that public health faces when combating new pathogens and the complex and very human decisions that impact your everyday health. I will be recommending this book to all my friends and family.

[Karen Cohn · Rating 5 out of 5]

Well-written in an easy to read style, this volume provides valuable information and insights about the history of epidemiology in this country, and the issues facing the future of epidemiology, in research, treatment, and funding.

[Libby · Rating 5 out of 5]

Public health is so awesome. ❤️
This book was so easy to read while also being so informative, a fabulous combination. I learned so much about the world of epidemiology and all of the work that goes into keeping us healthy. I loved it!

[Ali · Rating 5 out of 5]

I loved this so much. I am so fascinated by the history of disease and the approaches public health has taken to address them. This spans time and the globe, describing how disease shapes our world. It was also interesting reading how public opinion has shifted related to public health.

[Lisa · Rating 3 out of 5]

A good overview of past pandemics and avoided pandemics, up-to-date with COVID-19 information.

[Anjie · Rating 3 out of 5]

3.5⭐️

[Morgan Powell · Rating 4 out of 5]

I love a good public health book

[Gina Dalfonzo · Rating 5 out of 5]

A wise and valuable perspective on public health. Highly recommended.

[Michael G. Madden · Rating 5 out of 5]

Very well written and credible description of the challenges of Epidemiology.

[Lisa Kay · Rating 4 out of 5]

This a very digestible read that provides good information and good historical references with very little politics in my opinion.

[Sophia · Rating 5 out of 5]

This is such an interesting read full of very informative facts but also a profound amount of empathy about very hard subjects. Loved this so much.

[Brian Thorson · Rating 4 out of 5]

Introduction to public health efforts with focus on preventing the spread of epidemics.