6 Warnings and 1 Myth From Epidemics and Society
Many Saw it Coming. We Should Have Listened
Unfortunately, it appears far more people have read Frank M. Snowden’s masterpiece, Epidemics and Society, after the Covid-19 pandemic than before it.
Reading it during the original peak of the outbreak in the US was eerie. Many people saw it coming. Properly interpreting the warning signs and their potentially devasting impact.
These voices were increasingly marginalized in the run-up to the outbreak. With funds diverted or cut from monitoring programs.
Modern medicine had conquered disease, at least in the developed world, many believed. We no longer needed to be vigilant in identifying outbreaks as they were unlikely to occur.
A lesson we have painfully learned wasn’t true from our crippled response to the novel coronavirus outbreak.
Original Notes these warnings came from.
Warning 1 – Risk of New Diseases Emerging is Constant
Those who asserted the doctrine of the conquest of infection viewed the microbial world as largely static or only slowly evolving. For that reason there was little concern that the victory over existing infections would be challenged by the appearance of new diseases for which humanity was unprepared and immunologically naive. Falling victim to historical amnesia, they ignored the fact that the past five hundred years in the West had been marked by the recurrent appearance of catastrophic new afflictions—for instance, bubonic plague in 1347, syphilis in the 1490s, cholera in 1830, and Spanish influenza in 1918–1919.
Burnet was typical. He was a founding figure in evolutionary medicine who acknowledged, in theory, the possibility that new diseases could arise as a result of mutation. But in practice he believed that such appearances are so infrequent as to require little concern. “There may be,” he wrote, “some wholly unexpected emergence of a new and dangerous infectious disease, but nothing of the sort has marked the last fifty years.”5 The notion of “microbial fixity”—that the diseases we have are the ones that we will face—even underpinned the International Health Regulations adopted worldwide in 1969, which specified that the three great epidemic killers of the nineteenth century—plague, yellow fever, and cholera—were the only diseases requiring “notification.” Notification is the legal requirement that, when diagnosed, a given disease be reported to national and international public health requirements. Having framed notification in terms of a short list of three known diseases, the regulations gave no thought to what action would be required if an unknown but deadly and transmissible new microbe should appear.
Warning
Constantly improving science and technology increases the effectiveness of our response to diseases. As demonstrated by the historically unprecedented rapid reaction to the novel coronavirus outbreak.
It does not prevent outbreaks in the first place.
Warning 2 – Diseases Inevitably decline in virulence
belief in the stability of the microbial world was one of the articles of faith underpinning the eradicationists’ vision, a second misplaced evolutionary idea also played a role. This was the doctrine that nature is fundamentally benign because, over time, the pressure of natural selection drives all communicable diseases toward a decline in virulence. The principle was that excessively lethal infectious diseases would prevent their own transmission by prematurely destroying their hosts. The long-term tendency, the proponents of victory asserted, is toward commensalism and equilibrium. New epidemic diseases are virulent almost by accident as a temporary maladaptation, and they therefore evolve toward mildness, ultimately becoming readily treatable diseases of childhood. Examples were the evolution of smallpox from variola major to variola minor, the transformation of syphilis from the fulminant “great pox” of the sixteenth century into the slow-acting disease of today, and the transformation of classic cholera into the far milder El Tor serotype…
…infectious diseases that do not depend on the mobility of their host for transmission (because they are borne by vector, water, or food) are under no selective pressure to become less virulent; (2) overpopulated and unplanned urban or periurban slums provide ideal habitats for microbes and their arthropod vectors; and (3) modern transportation and the movements of tourists, migrants, refugees, and pilgrims facilitate the process by which microbes and vectors gain access to these ecological niches.
Warning
While diseases tend towards being less virulent as they evolve. As appears to potentially be happening with Covid-19. This does not eliminate the possibility of their evolving into more lethal forms over time as well.
Warning 3 – Overconfidence in Capabilities of Western Medicine
Memory of the power of public health and science provided impetus to the overconfidence of the transitionists, but forgetfulness also contributed. The idea—expressed by Surgeon General William H. Stewart in 1969—that the time had come to “close the book on infectious diseases” was profoundly Eurocentric. Even as medical experts in Europe and North America proclaimed victory, infectious diseases remained the leading cause of death worldwide, especially in the poorest and most vulnerable countries of Africa, Asia, and Latin America. Tuberculosis was a prominent reminder. Sanatoria were closing their doors in the developed North, but TB continued its ravages in the South; and it continued to claim victims among the marginalized of the North—the homeless, prisoners, intravenous drug users, immigrants, and racial minorities. As Paul Farmer has argued in his 2001 book Infections and Inequalities: The Modern Plagues, tuberculosis was not disappearing at all: the illusion persisted only because the bodies it affected were either distant or hidden from sight. Indeed, conservative WHO estimates suggested that in 2014 there were approximately as many people ill with tuberculosis as at any time in human history. WHO also reported that in 2016, 10.4 million people fell ill with tuberculosis and that 1.7 million died of it, making TB the ninth leading cause of death worldwide and the top cause of death from infectious diseases, ahead of HIV/AIDS.
Warning
The alarm felt in the developed world as Covid-19 spread. Is a permanent feature of life in emerging countries people have adapted to.
Warning 4 – Disarmament at the Wrong Time
An important reason for this new vulnerability was the legacy of eradicationism itself. The belief that the time had come to close the books on infectious diseases had led to a pervasive climate that critics labeled variously as “complacency,” “optimism,” “overconfidence,” and “arrogance.” The conviction that victory was imminent had led the industrial world to premature and unilateral disarmament. Assured by a consensus of the leading medical authorities for fifty years that the danger was past, federal and state governments in the United States dismantled their public health programs dealing with communicable diseases and slashed their spending; investment by private industry on the development of new vaccines and classes of antibiotics dried up; the training of health-care workers failed to keep abreast of new knowledge; vaccine development and manufacturing were concentrated in a few laboratories; and the discipline of infectious diseases no longer attracted its share of research funds and the best minds. At the nadir in 1992, the US federal government allocated only $74 million for infectious disease surveillance as public health officials prioritized other vital concerns, such as chronic diseases, tobacco use, geriatrics, and environmental degradation. For these reasons, informed assessments of American preparedness to face the unexpected challenges of emerging contagious diseases were disheartening.
Similarly, but more bluntly, Michael Osterholm, the Minnesota state epidemiologist, informed Congress in 1996: “I am here to bring you the sobering and unfortunate news that our ability to detect and monitor infectious disease threats to health in this country is in serious jeopardy. . . . For twelve of the States or territories, there is no one who is responsible for food or water-borne disease surveillance. You could sink the Titanic in their back yard and they would not know they had water.”17 Lederberg and other theorists of emerging and reemerging diseases developed a critique of eradicationist hubris that went deeper than a mere protest against a decline in vigilance. They argued that, unnoticed by the eradicationists, society since World War II had changed in ways that actively promoted epidemic diseases. One of the leading features most commonly cited was the impact of globalization in the form of the rapid mass movement of goods and populations. As William McNeill noted in Plagues and Peoples (1976), the migration of people throughout history has been a dynamic factor in the balance between microbes and humans. Humans are permanently engaged in a struggle in which the social and ecological conditions that they create exert powerful evolutionary pressure on microparasites. By mixing gene pools and by providing access to populations of nonimmunes, often in conditions under which the microbes thrive, globalization gives microorganisms a powerful advantage. In the closing decades of the twentieth century, the speed and scale of globalization amounted to a quantum leap as the number of passengers boarding airplanes alone surpassed 2 billion a year. Elective air travel, however, was only part of a far larger phenomenon. In addition there are countless involuntary immigrants and displaced persons in flight from warfare, famine, and religious, ethnic, or political persecution. For Lederberg and the IOM, these rapid mass movements decisively tilted the advantage in favor of microbes, “defining us as a very different species from what we were 100 years ago. We are enabled by a different set of technologies. But despite many potential defenses—vaccines, antibiotics, diagnostic tools—we are intrinsically more vulnerable than before, at least in terms of pandemic and communicable diseases.”18 After globalization, the second factor most frequently underlined is demographic growth, especially since this growth so often occurs in circumstances that are the delight of microorganisms and the insects that transmit them. In the postwar era, populations have soared above all in the poorest and most vulnerable regions of the world and in cities that lack the infrastructure to accommodate the influx. The global urban population is currently soaring at four times the rate of the rural population, creating sprawling and underserved megacities with more than 10 million inhabitants. By 2017 there were forty-seven such conurbations, such as Mumbai in India, Lagos… Some highlights have been hidden or truncated due to export limits.
Warning
Complacency is the wrong response to a lack of infectious disease in the world. The less disease is currently spreading. The more hospitable circumstances become for the next outbreak as the potency of our natural defenses decreases.
Warning 5 – Strength of Weapons is Fading
theorists of emerging diseases argue that antibiotics are a “nonrenewable resource” whose duration of efficacy is biologically limited. By the late twentieth century, this prediction was reaching fulfillment. At the same time as the discovery of new classes of antimicrobials had slowed to a trickle, the pharmaceutical marketplace staunched the flow by inhibiting research on medications that are likely to yield low profit margins. Competition, regulations mandating large and expensive clinical trials, and the low tolerance for risk of regulatory agencies all compound the problem…
…while antimicrobial development stagnates, microorganisms have evolved extensive resistance. As a result, the world stands poised to enter a post-antibiotic era. Some of the most troubling examples of the emergence of resistant microbial strains are plasmodia that are resistant to all synthetic antimalarials, S. aureus that is resistant both to penicillin and to methicillin (MRSA), and strains of Mycobacterium tuberculosis that are resistant to first-line medications (MDR-TB) and to second-line medications (XDR-TB). Antimicrobial resistance threatens to produce a global crisis, and many scientists anticipate the appearance of strains of HIV, tuberculosis, S. aureus, and malaria that are not susceptible to any available therapy.
Warning
Developing cures is hard and incentives aren’t always properly aligned to find them. Even when a cure is found. It’s capability to fight the targeted disease diminishes over time as infections evolve.
Warnings 6 – The variety of infectious diseases is increasing rapidly
the concept of emerging and reemerging diseases was intended to raise awareness of the most important threat of all—that the spectrum of diseases that humans confront is broadening with unprecedented rapidity. The number of previously unknown conditions that have emerged to afflict humanity since 1970 exceeds forty, with a new disease discovered on average more than once a year. The list includes HIV, Hantavirus, Lassa fever, Marburg fever, Legionnaires’ disease, hepatitis C, Lyme disease, Rift Valley fever, Ebola, Nipah virus, West Nile virus, SARS, bovine spongiform encephalopathy, avian flu, Chikungunya virus, norovirus, Zika, and group A streptococcus—the so-called flesh-eating bacterium. Skeptics argue that the impression that diseases are emerging at an accelerating rate is misleading. Instead, they suggest, it is largely an artifact of heightened surveillance and improved diagnostic techniques. WHO has countered that not only have diseases emerged at record rapidity, as one would expect from the transformed social and economic conditions of the postwar world, but that they gave rise between 2002 and 2007 to a record eleven hundred worldwide epidemic “events.” A careful examination of the question, published in Nature in 2008, involved the study of 335 emerging infectious disease (EID) events between 1940 and 2004, controlling for reporting effort through more efficient diagnostic methods and more thorough surveillance. The study concluded: “The incidence of EID events has increased since 1940, reaching a maximum in the 1980s. . . . Controlling for reporting effort, the number of EID events still shows a highly significant relationship with time. This provides the first analytical support for previous suggestions that the threat of EIDs to global health is increasing.”
Warning
More diseases emerging increases the chances of future outbreaks. The structure of the modern world will turn many of these outbreaks into pandemics.
Myth – Infectious Diseases can be Eliminated
In the stark words of the US Department of Defense, “Historians in the next millennium may find that the 20th century’s greatest fallacy was the belief that infectious diseases were nearing elimination. The resultant complacency has actually increased the threat.”
Comment
Many PHDs in history will be granted in this area of study.
Thank You for Reading
Last week I covered lessons learned from history we can apply to understand our post Covid-19 future.
He's published three books. Most recently The World After Covid 19: Coexisting with the Novel Coronavirus.
His musings can be found at stevenlmiller.me. Subscribe to The Pompatus Times for updates.
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