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The Profound and Enduring Impact of Coronavirus on the Way We Live
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Apollo's Arrow offers a riveting account of the impact of the coronavirus pandemic as it swept through American society in 2020, and of how the recovery will unfold in the coming years. Drawing on momentous (yet dimly remembered) historical epidemics, contemporary analyses, and cutting-edge research from a range of scientific disciplines, bestselling author, physician, sociologist, and public health expert Nicholas A. Christakis explores what it means to live in a time of plague—an experience that is paradoxically uncommon to the vast majority of humans who are alive, yet deeply fundamental to our species.
Unleashing new divisions in our society as well as opportunities for cooperation, this 21st-century pandemic has upended our lives in ways that will test, but not vanquish, our already frayed collective culture. Featuring new, provocative arguments and vivid examples ranging across medicine, history, sociology, epidemiology, data science, and genetics, Apollo's Arrow envisions what happens when the great force of a deadly germ meets the enduring reality of our evolved social nature.
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And [Apollo] descended from the summits of Olympus, enraged in heart, having upon his shoulders his bow and quiver covered on all sides. But as he moved, the shafts rattled forthwith upon the shoulder of him, enraged; but he went along like unto the night. Then he sat down apart from the ships, and sent among them an arrow, and terrible arose the clang of his silver bow. First, he attacked the mules, and the swift dogs. But afterward dispatching a pointed arrow against [the Greeks] themselves, he smote them, and frequent funeral piles of the dead were continually burning. Nine days through the army went the arrows of the god; but on the tenth, Achilles called the people to an assembly; for to his mind the white-armed goddess [Hera] had suggested it; for she was anxious concerning the Greeks, because she saw them perishing.
—Homer, The Iliad
CDC: Centers for Disease Control and Prevention, the leading government agency charged with epidemic control, based in Atlanta, Georgia.
COVID-19: The clinical disease caused by SARS-2, involving a range of symptoms and severities; also used to refer to the pandemic itself.
NIAID: National Institute of Allergy and Infectious Diseases, the leading government agency charged with scientific research into infectious disease, based in Bethesda, Maryland.
NPI: A nonpharmaceutical intervention, such as quarantining, used instead of or in addition to drugs to combat an epidemic.
PPE: Personal protective equipment, such as masks, face shields, gloves, etc., worn by health-care personnel and others to avoid contracting an infection.
SARS: Severe acute respiratory syndrome, a serious clinical illness involving shortness of breath that can result from infection with various pathogens or from other injuries to the lungs; also used as the name of a condition caused by the SARS-1 virus.
SARS-1: Virus from the coronavirus family that emerged in 2003 and caused a small pandemic.
SARS-2: Virus, also known as SARS-CoV-2, from the coronavirus family that emerged in 2019 and caused a large pandemic.
The gods of Greek mythology were ever present in my childhood. They were constant companions of my imagination, the subjects of my immigrant parents' bedtime stories, and even the names of children I played with when we visited our cousins in Greece. I was fascinated by the gods' duality: immortality and power contrasted with frailty and vice. The god Apollo, for example, was both a healer and the bringer of disease. During the Trojan War, with his silver bow and quiver of arrows, he rained a plague down on the Greeks to punish them for kidnapping and enslaving Chryseis, the daughter of one of his favored priests.
I found myself thinking again about Apollo and his vengeance as I contemplated our own twenty-first-century barrage more than three thousand years after the events described in The Iliad. It seemed to me that the novel coronavirus was a threat that was both wholly new and deeply ancient. This catastrophe called on us to confront our adversary in a modern way while also relying on wisdom from the past.
Despite the advances we have made in medicine, sanitation, communication, technology, and science, this pandemic is nearly as ruinous as any in the past century. Lonely deaths. Families unable to say goodbye to loved ones or perform proper funerals and acts of mourning. Destroyed livelihoods and stunted educations. Bread lines. Denial. Fear and sadness and pain. As I write, on August 1, 2020, over 155,000 Americans and over 680,000 people worldwide have died, and many more are still uncounted. A second wave of the pandemic is imminent, whether or not the hopes for a rapid vaccine are realized.
However, even in the midst of the onslaught, many people believe that the efforts to contain the virus have been excessive. Some Americans feel that our response has been overblown, yet another reflection of this nation's modern inability to accept hard realities. But I believe this thinking is wrong on two counts. First, it has required extraordinary force, including all our twenty-first-century wealth and know-how, to contain the virus to "only" this many deaths. I share the view of many good scientists that vastly more Americans would have died—perhaps a million—had we failed to deploy the resources we marshaled, belatedly, in the spring of 2020 to cope with the first wave of the pandemic. To compare this COVID-19 pandemic without mitigation efforts (or even with mitigation efforts!) to a typical flu season, as some have done, is a misreading of reality. Second, it is a misreading of history to think that in our time we would somehow be spared the burden of having to deal with a pandemic or that other people in other times have not faced the same fear and loneliness, the same polarization, the same fights over masks and business closures, the same call to neighborliness and cooperation. They have.
In late January 2020, as the virus was gathering force, I shifted the work of the many talented young scientists and staff in my research group at Yale to focus on it. First, working with Chinese colleagues, we published a study that used the mobile-phone data of millions of people in China to track the spread of the virus in January and February 2020. Then my lab began to plan studies of the biology and impact of the virus in the isolated region of Copan, Honduras, where we had a long-term field site and close relationships with thirty thousand residents in one hundred seventy-six villages. We also started exploring how mass gatherings, like elections and protests, might intersect with the spread of the virus throughout the United States. And in May 2020, we developed and released Hunala, an app based on network science and machine-learning techniques that people could use to assess their risk of infection.
The atmosphere in the whole scientific community in early 2020 was charged with urgency and probity. Colleagues all around the world pivoted to work on the coronavirus and broke down barriers to research, collaboration, and publishing. But very quickly it also became clear that there was an emerging vacuum of public information and few effective ways to communicate the problem that was unfolding. Along with a broad range of scientists, including epidemiologists, virologists, physicians, sociologists, and economists, I turned to Twitter to post tutorial threads on coronavirus-related topics such as the mortality rate in children and the elderly, the reasons we had to "flatten the curve," the nature of immunity after infection with the virus, and the extraordinary approach China had used to deal with the outbreak.
This book is another way I hope to help our society cope with the threat before us. In the middle of March 2020, Yale University closed down—though many laboratories, including my own, continued to work remotely. I wrote this book between March and August 2020 while in isolation with my wife, Erika, and our ten-year-old son in our home in Vermont. Our adult children intermittently sheltered with us as well, as they too were cut off from the lives they led before the disease struck.
I hope to help others understand what we are confronting, both biologically and socially, to outline how humans have faced similar threats in the past, and to explain how we will get to the other side of this, which we will, albeit after tremendous sorrow. The ability to understand a contagious and deadly disease builds directly on my years of teaching about public health, implementing global health interventions, serving as a hospice physician caring for the dying and bereaved, analyzing contagions using network science, and working as an academic sociologist studying social phenomena.
The COVID-19 pandemic is still a moving target, however. As of this moment, there is much that is unknown—biologically, clinically, epidemiologically, socially, economically, and politically. In part, the reason is that our actions are changing the outcome of the story. It's hard to know for sure what will happen. And there is much that only the passage of time will reveal, including the long-term health effects of the infection and the long-term consequences of our response to the contagion (such as how our physical and social distancing might affect the mental health and education of our children and the economic prospects of a generation of young people presently entering adulthood). We also do not know whether or when a vaccine will be available, how risky it will be, and how long the immunity it confers might last. Despite these uncertainties, we must all, as individuals and as a society, make the best decisions we can at the moment, informed by the broadest consideration of views and the best understanding of scientific facts.
The plague Apollo unleashed at Troy did eventually end due to the intercession of Achilles and of Hera, the queen of the gods. After ten days and many deaths, Apollo's terrible arrows ceased, and he put down his bow. Epidemics end. But how we get to that point defines us and our own moment facing down this ancient threat.
An Infinitesimal Thing
Humanity has but three great enemies: fever, famine, and war; of these by far the greatest, by far the most terrible, is fever.
—Sir William Osler, "The Study of the Fevers of the South" (1896)
In the late fall of 2019, an invisible virus that had been quietly evolving in bats for decades leaped in an instant to a human being in Wuhan, China. It was a chance event whose most subtle details we will probably never know. Neither the person to whom the virus gravitated nor anyone else was fully aware of what had transpired. It was a tiny, imperceptible change.
Scientists later came to suspect that this initial move by the virus might have happened at the Huanan Seafood Wholesale Market in Wuhan, because many of the first recorded patients were vendors or visitors there. But the picture was confusing. Huanan is known as a wet market because, as at many other markets throughout the world, one can buy fresh produce, fish, meat, and live animals there, and sometimes even wildlife (such as hedgehogs, badgers, snakes, and turtledoves). Some of these animals are butchered in the market, on the spot. Unlike the antiseptic supermarkets many of us are accustomed to, the pavements in such places are hosed down during the day to keep them clean. Hence, the markets are "wet."1
As far as we know, bats were not for sale at Huanan, though bats are consumed in China.2 In a prescient article published a year before the virus slipped unseen into our species, scientists suggested that "bat-animal and bat-human interactions, such as the presence of live bats in wildlife wet markets and restaurants in Southern China, may lead to devastating global outbreaks."3
The first person with a confirmed case of the disease that would come to be known as COVID-19 developed symptoms of severe acute respiratory syndrome (SARS) on December 1, 2019. There may have been other patients earlier; we do not know. However, this patient (and a few other early cases) did not have contact with bats or wildlife or the Huanan market. This has led to concerns that perhaps the virus initially leaped to humans in some other way, such as through researchers in Wuhan who collected samples of the virus directly from wild bats and analyzed them in laboratories with inadequate protective procedures.4 The Wuhan Center for Disease Control and Prevention, which does research with bat viruses, is just a few blocks from the Huanan market, and the Wuhan Institute of Virology is also a few miles away from it. However, Chinese authorities have claimed that there was no chance the virus leaked from these facilities.5
Notwithstanding the mysterious origin of the virus, 66 percent of the first forty-one people to contract the disease, during the month of December, did indeed have a direct connection to the Huanan market as shoppers, traders, or visitors.6 If the market was not the place where the virus first found its way to humans, it was the place where it first became easy for us to detect. The market, with its densely packed stalls and large number of people, provided a fertile environment for the virus to spread rapidly and easily, generate a localized cluster of cases, and therefore come to our attention.7
One of the first doctors to sound the alarm about the disease was Dr. Jixian Zhang of the Hubei Provincial Hospital of Integrated Chinese and Western Medicine. On December 26, 2019, she noticed seven cases of atypical pneumonia; three patients were in the same family, and four were from the Huanan market and knew each other. She reported them to the Wuhan Center for Disease Control the next day.8 Eventually, as part of an effort to cover up their initial inaction as the pandemic took root, the authorities gave her a merit award for reporting the cases.9 But later investigation revealed that there had been other cases of atypical pneumonia earlier in December, above the threshold for notifying the central Chinese Center for Disease Control in Beijing, that had gone unreported. Precious time to contain the outbreak was lost. In fact, a later analysis documented that there were 104 cases and 15 deaths during the month of December.10
The authorities began to realize what was happening and shut down the market on January 1, 2020.11 By then, the initial patients, dispersed to various hospitals, were being collected and transferred to a specially designated facility, Jinyintan Hospital.12 On January 27, 2020, analyses released by the Chinese CDC (and later regarded by some as possible misinformation) noted that 33 of 585 environmental samples (such as swabs of surfaces) collected at Huanan from January 1 to January 12 contained the RNA of a novel coronavirus, later named SARS-CoV-2. The positive samples were highly concentrated on surfaces in the western part of the market, where the wild animals were sold.13
On December 30, 2019, two days before the market was shut down, a thirty-three-year-old ophthalmologist, Dr. Wenliang Li, became aware of the emerging cluster of cases after reading an alarming report by one of his colleagues. Dr. Ai Fen, the head of the emergency department at Wuhan Central Hospital, had received a lab report for a patient with atypical pneumonia indicating that the patient had SARS.14 On a private WeChat group with a few medical-school classmates, Li spread the alarm. "There are seven confirmed cases of SARS at Huanan Seafood Market," he said. "The latest news is, it has been confirmed that they are coronavirus infections, but the exact virus strain is being subtyped. Protect yourselves from infection and inform your family members to be on the alert."15
By January 3, 2020, local authorities caught wind of Li's communications. There was a Chinese Communist Party meeting scheduled for later in the month, on January 12, and news of a local outbreak, much less a serious one, was not welcome. Indeed, until at least January 11, the public was wrongly assured that no new cases had been observed in Wuhan.16 Li was called to meet with the police and accused of "rumor-mongering" and "making false statements on the internet." He was forced to retract what he had said and sign a letter promising that he would not engage in "illegal activities."17 This was not the last time that the truth about COVID-19 would be suppressed or ignored as the pathogen spread around the world.
Of course, Dr. Li was completely correct. Later, the authorities would publicly apologize, and he would become a hero to ordinary Chinese people tired of constraints on free expression and disillusioned by misinformation from their leaders.18 Alas, as eventually happened to many other health-care workers in China (and in many other countries), Li died of COVID-19, on February 7.19 He had contracted the disease on January 8 while taking care of a glaucoma patient. That patient was a shopkeeper at the Huanan market.
The Chinese became aware fairly quickly that the disease could spread from person to person and was not independently and repeatedly acquired from a fixed animal reservoir. This worrisome fact was confirmed in a report about the first forty-one known cases published online in the British medical journal The Lancet on January 24.20 The Chinese were also aware that the disease was serious. Of these first patients, six (15 percent) died. The article concluded that the virus "still needs to be deeply studied in case it becomes a global health threat."
The virus spread—first slowly, then quickly—through Wuhan and then through all of Hubei Province, home to fifty-eight million people. By January, while the overall percentage of infected people in Wuhan was still tiny, it was high enough that when large numbers of people left the city, some of them carried the pathogen with them.
The virus had announced itself with extremely unfortunate timing, right at the start of the annual chunyun (春运) migration in China that was taking place in the run-up to the Lunar New Year festival, on January 25, 2020. During this period, over three billion trips are typically made, a mass movement that puts the annual Thanksgiving travel in the United States to shame.21 To make matters worse, Wuhan is a central transportation hub for China. Nearly twelve million trips were taken through Wuhan in January (as research in my lab, in collaboration with Chinese scientists, later documented), thus carrying the virus throughout China by the middle of February.22 The more people from Wuhan who went to a particular destination, as shown in figure 1, the worse the SARS-2 outbreak at that destination would later be. The initial "imported" cases set off local outbreaks via cascades of what epidemiologists term community transmission.
Authorities initially silenced voices like Li's, but later they abruptly yielded to reality and changed course—as other politicians in dozens of other countries would also eventually do. China scrambled to contain the outbreak, and more honest reporting was now encouraged. As Chinese president Xi Jinping said in his first public statements regarding the situation, on January 20: "It's necessary to release epidemic information in a timely manner and deepen international cooperation."23 The Communist Party's central political and legal affairs commission, a group not known for encouraging transparency, offered its own stern warning on a popular social media site in China: "Whoever deliberately delays and conceals reports will forever be nailed to history's pillar of shame." The post was later deleted.24
On January 17, nine days after Dr. Wenliang Li contracted SARS-2, seventy-two-year-old Dr. Lanjuan Li, a well-known physician and epidemiologist at Zhejiang Medical University in Hangzhou, one of China's oldest medical schools, learned from private communications that some medical personnel in Wuhan had fallen ill with a new kind of pneumonia.25 That day, she contacted the National Health Commission in Beijing seeking permission to go to Wuhan, and the next day, China sent her there as part of a six-member team. Also on the team was Dr. Nanshan Zhong, an eighty-three-year-old pulmonologist renowned for his role in identifying the nature and severity of the prior SARS viral outbreak in 2003. Both Li and Zhong enjoyed tremendous respect in China and around the world. Dr. George Fu Gao, the head of the Chinese CDC in Beijing, had been alarmed at what was happening in Wuhan (since hearing of informal reports in late December, he had been prodding local authorities to be more forthcoming), and he also joined the mission.26
On January 19, the team visited hospitals, the Wuhan Center for Disease Control and Prevention, and the Huanan market. The city's health-care system was already inundated. In a few days, China would begin construction of a 645,000-square-foot field hospital with thirty intensive care units and a thousand beds to supplement the existing infrastructure in Wuhan. Construction would be completed in ten days.27 On the evening of January 19, the team returned to Beijing and briefed the National Health Commission. Their report was alarming. At eight thirty a.m. the next day, January 20, the six experts took part in a cabinet meeting in Zhongnanhai, the Chinese leadership compound adjacent to the Forbidden City. Because the disease could spread from person to person, the team advised the government to implement stronger control measures, and they recommended closing off Wuhan. The Wuhan government announced at two a.m. on January 23 that it would impose a lockdown at ten o'clock that morning. A lockdown of the whole surrounding province of Hubei followed almost immediately.28
By January 25, nearly all of China was shut down.29 According to an analysis conducted by one of my Chinese students soon afterward, 934 million people lived in provinces that were subject to new rules, described as "closed-off management" (封闭管理). The scale of the practices, reminiscent to some extent of the degree of social control under Chairman Mao, was breathtaking. It was the largest imposition of public health measures in human history.
"Closed-off management" involved many features.30 People were required to shelter in their homes and were given permission to leave only once or twice a week for essentials. Shoppers waited in lines and kept six feet of separation between themselves and others—a development that stunned both local and foreign observers familiar with the usual press of bodies in China. And simply everyone wore a mask in public. Movement of people and vehicles was checked with special exit-entrance permits in every area, often down to the neighborhood level. Collectivist slogans made a reappearance everywhere, from little notations on these permits ("It is everyone's responsibility to fight the virus") to huge red banners in the streets. Every person's temperature was checked at the entrance to every community. Schools were moved online for millions of pupils. Vehicles and public places were regularly disinfected. Food and other essentials were carefully delivered on an enormous scale. The Chinese authorities encouraged delivery companies to distribute goods, and the companies vouched, via the ubiquitous apps used to place orders, that their drivers were wearing masks and did not have fevers.
The rules were enforced by block captains, local officials, and Communist Party members.31 This was made easier by the authoritarian government and collectivist norms in China, and enforcement of this new regime was not just top-down. For instance, rural residents set up crude roadblocks of felled trees to keep outsiders out, and they interrogated visitors in local dialects in order to detect interlopers.32
This control sometimes came with modern twists. In February, a state-run military electronics company released an app that allowed citizens to enter their names and ID numbers and be informed of whether they might have come into contact with a carrier of the virus while using planes, trains, or buses. This technology struck many people in countries around the world as creepy, yet similar ideas would soon strike them as desirable, even normal.33
The Chinese government began to gingerly lift some of these restrictions in some parts of the country in late March, but the Chinese continued to implement many other procedures on a large scale.34
- “Seldom have we been gifted with a study of pandemic disease marked by such scope, wit, and erudition. Still rarer is one that appears while the rest of us scramble to make sense of a rapidly evolving crisis, one shaped by the very social forces that Nicholas Christakis has studied for decades. Apollo’s Arrow is more than history’s first draft. It will live on as a journal of the plague years, certainly, and it inspires as it instructs. Definitive, engaging, and astonishing. A tour-de-force.”—Paul Farmer, Professor, Harvard Medical School, Founder, Partners in Health
- “The world is ravenous for deep and accurate information about the most important event in the 21st century. No one is deeper than Nicholas Christakis, who ticks every box of expertise: medical, epidemiological, social, psychological, economic, historical. This is the place to go to understand the phenomenon that has turned the world, and our lives, upside down. Apollo’s Arrow is gripping, enlightening, and vitally important.”—Steven Pinker, author of Enlightenment Now
- "In this brilliant and timely book, scientist, scholar, physician, and writer Nicholas Christakis shines the light of history on our dark moment, and illuminates it as no one else can. Insightful, informative, and urgently necessary, Apollo's Arrow is this year's must-must-read."—Daniel Gilbert, author of Stumbling on Happiness
- “Rich in psychological, sociological, and epidemiological insights, only Nicholas Christakis could write a book this comprehensive and profound and even optimistic during our national calamity."—Amy Cuddy, author of Presence
- "Wow, what a feat this is — a fully developed book of extraordinary insight and superb narrative structure that was somehow written in the midst of a live-action recording of events. The journalist in me marvels. The failures Nicholas Christakis captures are so enormously discouraging, infuriating, and tragic. I can only imagine how long this book will be read for reasons beyond the obvious. I burned right through it and highly recommend it.”—Michael Koryta, author of If She Wakes
- "Apollo’s Arrow shoots straight and true to explain the scientific and social aspects of the coronavirus pandemic. Christakis’s background in biology, medicine, epidemiology, and sociology is a powerful formula for understanding this complex subject. I’m tempted to say that the gods created Christakis to write this book at this time. It is wise, vivid, and engaging."—William D. Nordhaus, author of The Climate Casino, and 2018 Nobel Laureate in Economics
- “To capture the COVID-19 pandemic requires unusually broad and deep scholarship, and an ability to integrate the too-often siloed domains of science, medicine, epidemiology, sociology, psychology, politics, and history, among other fields. In Apollo’s Arrow, Nicholas Christakis accomplishes this challenging task as few others could, with unusual clarity and an endless array of surprising insights; this book will no doubt become essential reading for a very wide audience. A tour-de-force.”—Jeffrey Flier, MD, Former Dean of Harvard Medical School
- "An instant history of an event that is by no means over. Exceptional. Magisterial."—Niall Ferguson, Times Literary Supplement
- “Gripping. An indelible portrait of a world transformed.”—Hamilton Cain, Star-Tribune
- “Authoritative...A welcome assessment of the reality of the epidemic that has changed our lives.”—Kirkus Reviews
- “An excellent overview of the pandemic thus far, this work will be of interest to those seeking a full explanation of how we got where we are in terms of the virus and the direction we might be going.”—Library Journal
- “Provocative…Astutely shows how pandemics are as much about our societies, values, and leaders as they are about pathogens.”—Samuel V. Scarpino, Science
"Excellent and timely."—The New Yorker
- On Sale
- Oct 27, 2020
- Page Count
- 384 pages
- Little Brown Spark