Epidemiology in Tijuana: Drugs, Death, and Tracing an Epidemic

Book review: City of Omens, by Dan Werb (Amazon / Book Depository)

Perhaps epidemiology could reveal the hidden structures lurking just beyond reach, like asbestos behind wallpaper. Those structures might manifest as cruel calamities – car crashes, murders, HIV infections – that at face value appear unrelated. If that were the case, these women were not victims of a textbook epidemic, driven by an infectious agent that could be placed in a petri dish under a microscope. There was another pathogen lurking here, protean and murderous, distributing itself across this border town’s strange environment… I was desperate to return, to understand this place, to tell the story of an epidemic that I could not yet even name.

Newly minted PhD and epidemiologist Dan Werb was determining his next steps. He connected with HIV researcher Steffanie Strathdee (recent author of a book with her husband Tom Patterson, about saving Patterson from antibiotic-resistant bacterial infection with phage therapy.) She sent Werb to Tijuana, where he became perplexed by a mysterious, growing cluster of women’s deaths beginning around 2010, connected to the city’s HIV cases but bigger, more sinister, and threatening to spiral out of control: “Those singular causes of death – the decision to share a needle, take that client, run across that highway – were metastasizing into something else entirely. An epidemic.”

My job, [Steffanie] explained, would be to help delineate the contours of the epidemic so that she and her colleagues could understand its spread and develop programs – behavioral interventions, social services, infrastructure, or some still unknown approach – to contain it.

Werb is thorough in documenting the burgeoning epidemic and his scientific detective work. He explains the city’s makeup, as both its own sort of American Dream-like beacon for those from provincial areas of Mexico seeking work and improvement and for Americans, to whom it “offer[ed]…escape from the moral confines that their dream had imposed.”

Tijuana was more vulnerable to the destruction wrought by HIV … it is and was a city built on sex and drugs, its economic success propelled by the human appetite for risk.

The varying purposes in this influx contributed to a rise in cartel activity, gangs, drugs, sex work, and the ugly side effects of it all — HIV, disappearance, death, murder — disproportionately affecting women. He and his team are diligent, visiting encampments to interview and help addicts and sex workers, and enlisting the help of a former sex worker and heroin user in conducting these interviews and outreach.

Werb is an exceptional writer. I don’t expect scientists to write this eloquently — at times, even poetically — while still managing to distill their research, its complications and procedures understandably. Werb achieves it, making this unusually accessible, and despite not always being easy to absorb considering the bleak topics.

Still, there is a somewhat academic or densely scientific tone in certain passages, but less than might be expected for this kind of work. I was pleasantly surprised at how accessible the majority was, but some scientific explanations and data parsing were difficult for a lay reader.

Nevertheless, elsewhere it delivers and then some. Like when he explains how influenza originated in the mid-sixteenth century in China thanks to advancements in farming techniques, making a jump from ducks to pigs and finally humans. I had to reread this passage multiple times, not because I didn’t understand but because I couldn’t believe this was what happened. He tells mesmerizingly fascinating stories. And he does his best to make it understandable and readable, likening things as dry as statistical models to good art, explaining that they similarly “reflect the world as we know it and illuminate it further.”

Werb also greatly elucidates the field of epidemiology and its workings, why it’s unique among the sciences (their laboratory being the real world), and how with an HIV epidemic, there was so much work to do in terms of perception, faced as they were with trying to “strip the disease of any tinges of morality.” This was tricky because the epidemiologists could see how bad it was, and getting worse, but officials only considered tackling it punitively, not in any way to fix underlying issues. Werb is nonjudgmental, patient, and considerate in the work, and although no easy path out is identified, there’s hope in the efforts they’ve made.

The book highlights how societal problems compounded one another, and how this isn’t Mexico’s burden alone. There was no one single factor leading to the deaths and disappearances of so many women in the Zona, the borderland between Mexico and the United States, but rather a continuously swelling storm cloud of contributors. Werb has done incredible work in illustrating this complex, multi-faceted epidemic with engaging prose, and distilling it mostly accessibly for readers. The scientific aspects are fleshed out with history, drawing connections to the border and economic influence of the US, even to folklore and myth in Mexican culture, providing deeply atmospheric insights amidst the alarming science. A timely, critical and passionate study.

The Zona nowadays is like a bruise on the body of the border, an unwanted reminder of love or violence. But the history of the place demonstrates that this epidemic is not just Tijuana’s, and the border is no separator; a mere physical barrier cannot achieve that aim… If anything, the imposition of the border along the edge of the Zona has revealed one important truth: the higher the wall, the deeper the secret.

City of Omens:
A Search for the Missing Women of the Borderlands
by Dan Werb
published June 4, 2019 by Bloomsbury USA

I received an advance copy courtesy of the publisher for unbiased review.

Amazon / Book Depository