Read the next installment: “Zoonosis: How animal diseases become human diseases”
Read the previous installment: “Evolution: How a virus becomes a threat“
If an enterprising bookmaker decided to offer odds on which apocalyptic event is most likely to wipe out the human race, a pandemic would rank higher than any nuclear attack, robot uprising, or hurtling asteroid. Epidemiologists and healthcare professionals from across the globe agree: despite (scrambling, often uncoordinated) efforts by governments and agencies to prepare for the worst, the world is wholly unready for a global outbreak of a deadly infectious disease. In February 2017, Bill Gates warned that, unless drastic measures are taken soon, a fast-moving airborne pathogen “could kill more than 30 million people in less than a year.”
Of all the emerging disease threats, an influenza outbreak is the most worrying, due, principally, to the speed with which flu can spread and the virulence with which it can kill. Recent research has proved beyond reasonable doubt that the 1918 Spanish flu, which killed between 50 and 100 million people and was the deadliest in human history, originated in birds. Today, new avian flu strains that carry unprecedented mortality rates, like the H5N1 strain that appeared in Hong Kong in 1997, are emerging more regularly than ever before.
Chief among these new threats is H7N9, a flu strain originally found in a Chinese chicken that the U.S. Centers for Disease Control and Prevention (CDC) currently regards as having the greatest potential to cause a deadly pandemic should it mutate and become airborne. The virus was first detected in a human victim in 2013. Figures released last month indicate that H7N9’s most recent outbreak, in October 2016, killed more people in China than the previous four bird flu outbreaks combined, and produced a variant that is less susceptible to vaccines.
While the prime suspect is clear, there is a problem when it comes to preparing to deal with H7N9 at a global scale. As Dr. Keiji Fukuda, former chief of epidemiology at the CDC, puts it, humanity has “dodged a bullet” when it comes to pandemics in recent years. Through a combination of preparedness, swift action, and bald luck, neither SARS in 2002, swine flu in 2009, nor ebola in 2014 have yet blossomed into full pandemics. As such, we have few reference points to provide clues or models for what a world in the throes of a contemporary deadly outbreak could look like–and how, in our connected society, we might best prepare for the worst.
Irwin Redlener is the director of the National Center for Disaster Preparedness at Columbia University. He and his team have spent the past 14 years studying disasters, be they caused by climate change, terrorism or sickly chickens. Using data and computer models, they’ve explored the various scenarios that may unfold following the emergence of a new lethal and virulent strain of avian influenza–and the outputs of those grimly prophetic models read like zombie fiction.
Let’s say the virus, a variant of H7N9, is first detected in a patient who was exposed to live poultry in one of China’s rural bird markets, where the rigor and regulation currently applied to many of Hong Kong’s markets has yet to be implemented. A week later, three more cases are detected, and the patient dies in hospital of a lung infection.
A laboratory run by the CDC in Atlanta is the first to examine a blood sample taken from the victim. The CDC’s virologists confirm that they have detected a new strain of avian influenza. The Chinese government, well practiced in dealing with such outbreaks, orders the shuttering of live bird markets and the slaughter of tens of thousands of birds in the province where the first cases were discovered.
After a few days, however, hospitals are still being inundated with new cases; it’s clear that neither the cull nor the country’s meticulous rules for transporting live animals are proving effective. This new virus, it seems, can spread from human to human, through the air that we breathe.
Days later, cases of the infection are reported in China’s neighboring countries, although it’s unclear at this stage whether the virus has been spread by truck drivers crossing borders, or birds migrating for the winter.
Almost immediately, Redlener predicts, international airports will begin to close in an effort to prevent trans-oceanic transmission. Air travel, where strangers from far-ranging geographic regions with different levels of disease vulnerability are forced into a closed space for a sustained period of time, is currently the fastest way for disease to travel between counties.
Like the trenches and canvas hospitals of the 1918 Spanish flu outbreak, a plane acts as an incubator for a virus, infecting passengers who, on disembarkation and dispersal, then distribute the virus with scattershot efficiency. As Ed Yong at The Atlantic recently put it, when it comes to spreading disease, “By criss-crossing the skies in countless planes, we transform small fires into global conflagrations.”
The airport closures come too late to stop the pandemic’s spread. In today’s connected world, a disease can be transported from a rural village to any major city within 36 hours, faster than any government could implement a no-fly policy. The first cases are reported in Europe and, shortly thereafter, in the U.S. In these early weeks, misinformation abounds, just as it did during the ebola outbreak in 2014, when false reports helped accelerate the virus’ spread. On cable news channels, some pundits suggest that the outbreak is the result of irresponsible genetic research in China. Others suggest that it its part of a terrorist plot.
The schools begin to close. “One of the most important things to do in an emerging pandemic is to reduce transmission among children,” Redlener says. But pandemic models show that this precaution creates as many problems as it solves. “Who takes care of the children at home?” asks Redlener. “What if the parents themselves become sick? And what happens to the economy when the parents can no longer work? How do people buy food if they’re not bringing in an income?”
Supply chains begin to collapse as the local and regional economic consequences of the pandemic emerge. “Who delivers our day-to-day supplies of food and medication, and whatever else one needs if there are people sick all over the place?” Redlener asks. “Are we going to allow interstate truck transportation if doing so increases the risk of spreading the disease?”
Within weeks supermarket shelves sit bare. The lines at gas stations stretch lingeringly along the highway–at least, for those short days before the pumps squeeze dry.
The fragility of every highly-tuned mechanism that ensures the comfort and ease of contemporary life in richer countries is slowly and fully revealed. The global health crisis moves from “being on no one’s to-do list to being the only thing on their list,” Bill Steiger, who headed the Office of Global Health Affairs during the George W. Bush administration, told the Washington Post in April while discussing pandemic preparedness.
As the CDC issues daily advisories (stay home, wear masks, cover your mouth when coughing), President Trump responds with characteristically extravagant rhetoric. This time, however, the rhetoric carries through to even stronger measures. The U.S. borders with Canada and Mexico are closed, martial law is declared, and sick Americans are quarantined (and placed in detention camps if found to break curfew). Banking on public sentiment about those epidemic conspiracies, Trump launches a trade war with China.
As the pandemic takes hold, we begin to see the inadequacies of individual nations’ capacity to respond. Hospitals, medical staff, and medicines are tested in unprecedented ways. “There’s been very little improvement in the U.S. capacity to deal medically in terms of the response to a pandemic,” says Redlener. “We don’t have enough antiviral agents. We don’t have enough mechanical ventilators. It’s very dicey as to whether and how we would take care of people that need to be hospitalized in the event of a pandemic. Right now we would simply be overwhelmed with patients.”
This is where the full alien complexity of a pandemic scenario is revealed: by considering the ethical questions that will be kicked up in the throes of disaster. What happens, for example, when hospitals run out of mechanical ventilators? Will a doctor be able to tell a parent that, as their child’s chances of survival are slimmer than those of a young adult, their hospital ventilator must be requisitioned? “There are simply no guidelines for how we manage the huge shortages we will encounter in the healthcare system in the event of a pandemic,” Redlener says.
Whether these hypothetical occurrences are plausible or far-fetched, Redlener believes that the cascading consequences of any pandemic are far beyond the scope of many disaster planners’ current considerations. Models may show how quickly a virus could travel the world, but they don’t elaborate on the full extent of the implications of societal collapse in the midst of a deadly pandemic. The entire world, Redlener says, is “profoundly unprepared.”
Redlener and his colleagues are not the only ones reaching these apocalyptic conclusions. In 2011, the World Heath Organization introduced a global initiative called the Pandemic Influenza Preparedness (PIP), a program designed to stop or delay pandemic influenza at its initial emergence and prevent the kind of global disaster envisaged above.
As part of the PIP, a network of more than 150 laboratories around the world known as the Global Influenza Surveillance and Response System now monitors outbreaks of flu, testing blood samples from newly infected patients and monitoring pharmacy sales of medications used for treating flu symptoms. This research informs the creation of the seasonal influenza vaccines, new versions of which are developed twice a year, and provides the basis for the advice the World Health Organization hands out to governments to help them prepare for a pandemic.
Many individual nations have developed their own specific plans. The UK, for example, has the Notifiable Avian Disease Control Strategy, which sets out procedures that must be followed after the emergence of a pandemic-ready disease on the island. But the World Heath Organization is working to better coordinate efforts and strategies between nations, based on the experience from the 1918 Spanish flu–you can’t fight a pandemic by treating individual patients alone. They believe a modern pandemic is only defeated by treating the interconnected world, not individual nations.
“A pandemic is nothing short of a global event,” says Sylvie Briand, director of the Infectious Hazard Management Department within a newly-established World Heath Organization emergency program. “It must be managed at both the national level and international level. A disease does not acknowledge borders.” Pardis Sabeti, a leading infectious-disease researcher from Harvard University, told The Atlantic the same thing earlier this year: “Viruses are global threats to humanity. They’re everyone’s problem. In some ways, they’re the one unifying threat.”
Still, the threat posed by pandemic influenza differs depending on the country from which it emerges. “The problem is that up until now, influenza is seen as a disease of rich and temperate countries,” says Briand. “That’s not the case. Influenza is everywhere. But in many tropical countries, where there is a high mortality rate due to respiratory diseases, most of the time, they don’t even know that this is due to influenza.”
In 2014, the Obama administration committed $1 billion to a newly-launched partnership known as the Global Health Security Agenda. The program is intended to help prevent deadly outbreaks from spreading by strengthening basic public health systems in countries least equipped to fight epidemics. It has provided epidemiology training to healthcare professionals Mali, for example, and helped governments develop emergency operations to deal with an outbreak of avian influenza. More than 30 countries have taken part in evaluations to assess their ability to detect and prevent outbreaks (the results, even negative ones, are made public). Progress is, however, “still fragile” and “require[s] continued funding,” according to an internal CDC analysis.
The current efforts to improve international collaboration are heartening. But in the tumult of a pandemic event, we cannot predict how nations may react when asked to provide practical support for one another.
“When, say, there’s a huge coastal storm in the northeast of the U.S. or something like Katrina in the Gulf region, help usually flows in to the disaster area from other cities and regions,” explains Redlener. Those who are unaffected, in other words, typically support those who are affected. “But a pandemic threatens everyone, everywhere. Boston cannot expect to receive extra ventilators from New York or D.C. or Chicago because those cities are going to need everything they have.” Resources are limited and, at every level, from the neighborhood to the city to the nation, the human instinct to look after one’s own inevitably kicks in.
“It requires a lot of work to make sure that collaboration exists during a crisis,” says Briand. “The tendency is for each country to stockpile vaccines and execute its own individual preparedness plan. But we need to add a supranational layer of preparedness, to make sure that it’s not first come, first served. This is what may happen in case of a global event: the richest country will access vaccines and the others won’t.”
Part of the problem for anyone involved in this grim and difficult business is that foresight is much harder to act upon than hindsight. Vaccination is by far the most effective way for humanity to defend itself against a pandemic. Yet, as Redlener puts it, the cogs and wheels of capitalism work against the research, development, manufacturing, and stockpiling of vaccines (some of which reach their expiry date within 12 months). “In a private system of manufacturing and development and research,” he explains, “pharmaceutical companies might not be able or willing to invest large amounts of money in something that they won’t see and can’t predict a return on.”
Meanwhile, the World Health Organization’s laboratories continue to work on increasing the speed at which medication can be prepared in advance, hoping to reduce the lag time for the development of a new vaccine from at least six months down to four. The speed at which flu can spread is integral here: the 1918 flu, notably, killed more people in 24 weeks than AIDS killed in 24 years.
Today the World Health Organization has secured 500 million doses of general flu vaccines–but they may not be effective against a new strain of avian influenza. These reserves, Briand says, will enable the world to tackle the first wave of a pandemic. But Redlener, by contrast, is adamant that the stockpile will be woefully inefficient. “We don’t have enough flu vaccine of any kind that would be able to stem a major pandemic–certainly not a deadly pandemic that was highly transmissible.”
Domestic and international politics play a crucial role in creating the kinds of collaboration that are needed to confront the potential of global pandemics. Yet as Brexit and the rise of nationalistic rhetoric on the world stage demonstrate, this collaboration is on increasingly shaky foundations.
“Donald Trump’s been very overt about this “‘America First’ concept, which is retrograde and inappropriate in terms of almost all of the major problems the world is facing–economics, public health, dealing with climate change,” says Redlener. Indeed, within his first few weeks in office, Trump proposed sharp cuts to government agencies working to stop deadly outbreaks at their source.
During the ebola outbreak in 2014, Trump tweeted that American aid workers should not be allowed back into North America (“KEEP THEM OUT OF HERE!” he wrote), lest they spread the disease. It’s a mindset that suggests Trump would be reluctant to send American aid to help with outbreaks in other nations. “Fragmenting our individual countries only increases the threat posed by a pandemic,” says Redlener.
For the World Health Organization, the need for ongoing international collaboration is crucial not just in the event of a pandemic, but in staging drills and fortifying ourselves for such an event. “Preparedness requires a continuous effort,” says Briand. “Mechanisms are strong only if you use them often. People change, orientation changes, so you must constantly carry out simulation exercises to make sure that a plan is up to date, and that you are truly ready to face the unexpected.”
When can we expect the emergence of another fowl plague? Every expert interviewed for this series said that a major pandemic is not only likely, but perilously imminent.
The World Health Organization is currently monitoring a number of avian flu viruses that, according to Briand, “have pandemic potential.” Among them is the newly-discovered H10N8, a disease of unknown origin that killed its first human victim in China four years ago. Since then the CDC has monitored more than 300 outbreaks in 160 countries, tracking 37 dangerous pathogens in the last year alone.
We are clearly not prepared. How could we be? Societal collapse cannot be meaningfully rehearsed. Healthcare systems around the world already struggle to deal with the demands of our growing and ageing populations, let alone those that would be exerted following a pandemic catastrophe. Meanwhile, xenophobia and other nationalistic, inward-looking stances are antithetical to the international politics and collaboration required to stop local outbreaks from becoming pandemics.
In his January op-ed, Bill Gates wrote that he’s optimistic, and that with some effort, humanity could still avoid the worst. “A decade from now, we can be much better prepared for a lethal epidemic–if we’re willing to put a fraction of what we spend on defense budgets and new weapons systems into epidemic readiness.”
But that willingness is, as Redlener puts it, “yet to manifest.” Until it does, we continue to live under a looming shadow, cast by the birds that fly across a grey and gathering sky.
Read the next installment: “Zoonosis: How animal diseases become human diseases”
Read the previous installment: “Evolution: How a virus becomes a threat“
How We Get To Next was a magazine that explored the future of science, technology, and culture from 2014 to 2019. Fowl Plague is a five-part series that explores the history of deadly global pandemics–and asks whether we’re ready to respond to the next one.