I purchased this book from @bookofthemonth to read. All opinions are my own. 🌟🌟🌟🌟 City of Omens by Dan Werb. This fact filled book begins with epidemiologist Dan Werb studying drug addiction and the spread of HIV in Tijuana but he quickly learns with the right questions asked he can find answers to a larger puzzle. Missing women, a lot of missing women. Drug overdoses, HIV transmission, environmental toxins killing women at an increasing rate. He is trained to track facts and sort data that leads to the deaths of the most vulnerable inhabitants from multiple cultures and walks of life. This research casts a new light on border policy, addiction, and human trafficking. This book does read like a documentary though and that's where the story slows. However, it must be written that way to include all the data and facts and stories that lie within its pages. Review also posted on Instagram @borenbooks, Library Thing, Amazon, Twitter @jason_stacie, Goodreads/StacieBoren and my blog at readsbystacie.com ( )

The most famous and successful epidemiologist was John Snow. He singlehandedly stopped a cholera epidemic in London 150 years ago. He tediously marked all the unexplained deaths on a map, showing how they intensified geographically toward a central point. Visiting that spot, Snow found a public water pump. By breaking off the handle, he stopped the epidemic right then and there. Things are not usually that clear cut. In City of Omens, Dan Werb applies Snow’s and all the modern tools available to solve a current plague in Tijuana. Women are turning up dead. It is so disproportionately high he calls it femicide.

Epidemiology is detective work. It can show where our conclusions ad assumptions are wrong. Werb gives some great examples. Doctors had always thought that drug addicts were psychopaths, and assumed so when an addict showed up. That stopped when studies began to show that doctors were most liable to become addicts (as many as 50%) themselves. Similarly, American troops in Viet Nam had a heroin habit among 30% of them. Considering these situations as epidemics rather than psychiatric problems has changed the way we approach them. We’ve also discovered that bad neighborhoods don’t create addicts. Addicts drift towards them as they both decline, making both worse. The UN describes an epidemic as when a condition affects more than 10 people per hundred thousand. An epidemic becomes endemic when it is a regular occurrence, like flu in winter. The bulk of the book is about death rates in Tijuana, where murders had been closer to 40 than ten.

In the case of Tijuana, the inputs were numerous and well known: prostitution, drugs, HIV, shared syringes, corrupt police, drug cartels, violent drunks. Werb describes Tijuana as chaotic, with all of these factors applying to daily life. The pathogens were not airborne or waterborne microbes. They were corrupt people. They all involved the rapid spread of HIV, and together left a trail of bodies, literally on the streets of the city. Narcos attached notes to decapitated bodies saying let this be a lesson. Eventually, on top of everything else, there was gang war for control of the drug business. Narcotics money bought off everyone worth buying, keeping the violence levels elevated.

There is an endless supply of women streaming to Tijuana. They are attracted to the maquiladoras, the free trade zone factories that employ 200,000. The steady work turns out to be more like slave labor, and worn out women quit, going into sex work to survive. Sex work inevitably means poverty, drugs and shared needles, so disease spreads fast.

Epidemiology has another interesting aspect – it can be counterintuitive more often than not. Werb has to keep saying he was wrong. In the case of Tijuana, Werb found that increased methadone use led to decreased heroin use, which meant less spreading of HIV. Methadone costs more than heroin. The methadone use was correlated with higher bribes to police. Those who gave more to the police had better survival rates. This is not intuitive, and Werb had to figure out that people on methadone had to make more money than those on heroin, so they became bigger targets for police extortion. Overlaying the database of police beatings on maps showed clusters around the methadone centers, which turns out to be why more people did not enter the programs. This was an unexpected reason for its limited success. Nothing is simple.

Two tectonic shifts accelerated the disaster in Tijuana, Werb says. The HIV scare in the 80s caused the US Navy to send 800,000 condoms to Tijuana, because the Navy “appreciates” sex work all over the world. But the rapid increase in HIV among sailors made the Navy eventually and suddenly forbid all leave in Tijuana. San Diego County has more than 50 military bases with over 100,000 sailors, so this was big for Tijuana. Then 9/11 caused uncontrollable fear in the USA. George Bush responded with a wall 580 miles long to seal off Tijuana for some reason. Even legal border crossings fell. They dropped from their record 110 million to 71 million a year. Business in Tijuana plummeted. Sexworkers took to dealing drugs, and murders of women soared from less than ten to over 40 per hundred thousand, making it a certified epidemic.

The small irony of City of Omens is that in order to decide the global effects and origins of an epidemic, the epidemiologist spends all his/her efforts on the minutest of details. From repeatedly interviewing survivors, to examining the unique aspects of the streets, buildings, neighborhoods and environs, it is all very fine-grained. There is a lot of legwork involved. It is akin to ethnography. The biggest challenge seems to be seeing the forest while among the trees. So the book is massively descriptive, far more than one would expect from a book on epidemics. City of Omens does show the potential value of epidemiology. Unfortunately, Tijuana is not a success story. In 2018, 2300 were killed there, a rate of 135/100,000. Money talks.

David Wineberg ( )