by Bryan Walsh
All of the above are reasons why Trump lacks the talent and the temperament to lead the United States through an outbreak, just as he has proven himself unfit to control the nuclear codes, just as he has shown himself to be a major obstacle on climate change efforts. But there’s something else about Trump that would make him dangerous in the face of a new disease. Public health is built on a foundation of trust with the public—trust about the often uncertain facts around an outbreak, and trust that doctors and the government know what they are doing. Whatever you might think of Donald Trump as president, it is impossible to ignore that he has acted again and again to erode trust in his own government—fighting with his own intelligence officials over Russian election hacking or Saudi Arabian assassinations, censoring the science produced by his own agencies.72 The consequences of those spasms of interference have been bad enough already. If the president conducts a Twitter war against government doctors during an outbreak, people will die.
It’s discomfiting to imagine Trump or someone like him in charge during the next SARS or Ebola outbreak, but even a far more capable leader would struggle to contain an outbreak of a new and contagious disease. Take vaccines, one of the major reasons why you’re much less likely to die from infectious disease than your great-great-grandparents were. The middle of the twentieth century was a golden age for vaccines, as scientific heroes such as Jonas Salk developed protections against life-threatening diseases like polio and measles. Yet while the worldwide pharmaceutical market is worth more than $1 trillion today, the market for vaccines makes up only 2 to 3 percent of it.73 Given that it can take ten years of testing and billions of dollars to develop a vaccine74—and given that attempts have an estimated 94 percent chance of failure75—drug companies have shied away from the business.
Ebola is a case in point. An early-stage vaccine existed for years before the West Africa outbreak, but with little commercial incentive to develop something that would prevent a rare disease that at the time only menaced the developing world, work languished. Global health authorities fast-tracked candidates during the 2014 outbreak but the disease was ultimately contained76 before a vaccine was close to ready. After the crisis ended, some of the companies involved in preparing the vaccine complained that they had spent millions on a product that no one now wanted to buy. “Vaccines are a major market challenge,” said Trevor Mundel, the president of the global health division at the Gates Foundation. “There’s just no incentive for any company to make pandemic vaccine to store on shelves.”
No disease better illustrates that conundrum than influenza. There is a healthy market for seasonal flu vaccine, and it does prevent tens of thousands of hospitalizations and millions of illnesses each year.77 But the flu vaccine is far from perfect—the 2017–18 flu shot was only 36 percent effective, even worse than it is during an average year.78 Because flu viruses mutate constantly, a new vaccine has to be developed and manufactured every year to match the latest strain. Months pass from the development of a candidate strain in a lab to the moment the vaccine is loaded in a syringe in your doctor’s office. Scientists developing the vaccine are forced to predict which flu strain will be circulating nine months in the future, when the vaccine will finally be ready for use. Some years—like the 2017–18 flu season, which saw record-breaking hospitalization rates in the United States—they choose poorly.79
A mismatched vaccine is an annoyance when the result is a nasty case of seasonal flu. But it would be deadly during a severe influenza pandemic. Such pandemics are the single event that infectious disease experts fear the most—flu, said Dr. Frieden, is the “big one.”80 Humans have little to no immune protection against these new flu strains, so when they emerge they spread rapidly around the world. Hundreds of millions of people get sick, and if the new strain is especially virulent, tens of millions could die. That happened during the 1918 flu pandemic, still the standard for what a global disease disaster could do to a mostly modern world. Three other flu pandemics have occurred since 1918, and scientists know that a new pandemic is inevitable.
Flu vaccines didn’t exist in 1918, but they did in 2009, when a new strain in Mexico jumped from pigs to people. Even though the government and the pharmaceutical industry tried to fast-track a new vaccine, however, the first doses weren’t available for 26 weeks, and it would have taken 48 weeks to produce enough to vaccinate every American.81 By then the pandemic would have already run its course.82 The virus moves swifter than we do.
One way to catch up would be to develop what is known as a “universal” flu vaccine. While seasonal flu vaccines focus on genetic parts of the influenza virus that are easy to target but which mutate constantly—which is why the vaccines quickly fall out of date—would-be universal vaccines aim for sections of the virus that remain stable from strain to strain. If successful, they could provide years or even a lifetime of protection in a single shot—including from future pandemic strains. The work is a scientific challenge—at a meeting on universal flu vaccines in 2018, one expert said that the field was essentially in the same place now as it had been in the 1960s.83 But we’re spending only $160 million a year on universal flu vaccine research, compared to the more than $1 billion annually that goes to HIV vaccine work.84 I would never argue that we need to spend less money developing a vaccine for a disease like AIDS that has already killed tens of millions of people, but the damage a severe influenza pandemic could do to this planet is far worse. Yet we don’t take it seriously enough to properly fund research into the one tool that could retire the risk of a flu pandemic altogether.
Since we’re unlikely to have a vaccine available to protect us from the next pandemic, we’ll need to get better at containing them before they get out of control. The example of Ebola, though, demonstrates how porous our global response system is. The WHO responded far too slowly to Ebola. It wasn’t until August 8, 2014, when there had already been more than 1,700 recorded cases, that the agency declared Ebola in West Africa a public health emergency of international concern—its highest alert.85 The agency has been largely unable to stop a new Ebola outbreak that began in the Democratic Republic of Congo in 2018 and had surpassed 1,000 cases by March 2019, making it the second-biggest outbreak of the disease on record.86 But the WHO is asked to do far more than its resources allow. The agency responsible for the health of the entire world has an annual budget of just $2.2 billion—equivalent to that of a single large American hospital.
By the WHO’s global standards, the United States has a strong health system—which doesn’t mean it’s ready for the stresses of a major pandemic. Unlike other natural disasters, which tend to be confined to a single location or region, disease can strike almost everywhere at once. Hospitals that on normal days have enough beds and mechanical ventilators to function would be overwhelmed by needy patients, as would other nearby hospitals, leaving nowhere to turn for help. A global economy that depends on just-in-time delivery for basic parts and long, often international supply chains would be fatally disrupted by a prolonged outbreak. That includes the medical industry—many of the drugs that keep American patients alive are manufactured outside the United States. If police and government officials fall sick, public safety might be the next casualty. “Even though it is an ‘act of nature,’ a pandemic is much closer to war,” writes the public health expert Michael Osterholm in his 2017 book, Deadliest Enemy. “As in war, in a pandemic, there is greater and greater destruction day by day, with no opportunity for recovery.”87
Infectious disease is where the natural and the man-made meet and multiply. Pathogens have always been a fact of human life—leprosy, a chronic infection caused by the bacterium Mycobacterium leprae, has been sickening human beings since at least the dawn of civilization88—but our infrastructure, our decisions, our climate, and our leaders all influence the course a sickness will take. We’ve built a world that amplifies the opportunity for a new virus to leap from an animal to human, and from there to any other spot on the globe. That’s why the rate
of new diseases and new outbreaks is growing. A globalized, interconnected planet of more than seven billion people is a feast for viruses. In a 2015 TED Talk, Bill Gates—who has dedicated his post-Microsoft career to disrupting infectious disease as he once disrupted the software industry—said something that struck me. “When I was a kid the disaster we worried about most was a nuclear war.” But today, he continued, “if anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus, rather than a war. Not missiles, but microbes.”89
As frightening as a pandemic is, we know how to solve disease in a way we clearly don’t for climate change, or won’t for nuclear war. While the existential threats from emerging technologies like artificial intelligence present us with question marks, the fight against infectious disease has the benefit of history—and over the course of history, we’re still winning, as I learned on a rainy Boston morning in 2018 when I visited Dr. Marc Lipsitch at his office at Harvard’s T. H. Chan School of Public Health.
Lipsitch is one of the most influential epidemiologists in the United States, and one who takes seriously the possibility that disease pandemics might constitute a true global catastrophic risk—which is why I was there to see him. But that morning Lipsitch showed me something I wasn’t expecting: a chart that graphed infectious disease mortality in the United States over the course of the twentieth century. He includes the slide in his epidemiology courses, and what it shows is a drastic decline, from around 800 deaths from infectious disease per 100,000 people in 1900 to about 60 deaths per 100,000 by the closing years of the century. There was a brief spike in 1918—that would be the flu—and a slight and temporary upturn during the worst of the AIDS epidemic in the 1980s. But, Lipsitch told me, “death rates from infectious disease dropped by nearly one percent a year, about 0.8 percent per year, all the way through the century.”
At first I assumed the graph represented the success of vaccines and antibiotics. It does, but Lipsitch pointed out to me that the decline in death rates began years before the introduction of vaccines to diseases like rabies, typhoid, or yellow fever, and decades before the first antibiotics came into use. Even as American cities were bursting with new arrivals and potential disease hosts in the early twentieth century—New York City’s population had already reached 3.4 million by 1900, and would grow by an additional 2 million over the next two decades alone—rates of death from infectious disease had already begun falling.90 So what happened?
One theory is that the introduction of water filtration and disinfection in cities eliminated the threat from waterborne diseases like typhoid and cholera that had long winnowed urban populations. Another is that people simply became healthier—better fed, more robust, richer—which made them more likely to survive infectious diseases of all kinds. And assuming those trends continue, we should be even more resilient in the decades to come. “I think these are really, really big risks,” Lipsitch told me. “But I don’t think infectious diseases are really existential risks.”
Even the 1918 flu virus, spreading in the days before vaccinations or antibiotics, grew less lethal as the pandemic wore on, which is exactly what evolutionary biologists would have expected. Paul Ewald, the director of the program in evolutionary medicine at the University of Louisville, told me that “particularly nasty” variants of the flu virus arose in the crowded and dirty trenches and army bases of World War I Europe. The horrific and unusual conditions there—a sudden and temporary reversal of the increasingly hygienic twentieth century—meant that even a pathogen that killed in a day, as the 1918 flu sometimes did, could continue spreading unabated, just as a wildfire burns easily in a hot and dry forest. “But the flip side is that as the flu spread around the world it quickly evolved to become milder,” said Ewald. “And those milder strains won out in an evolutionary contest.”
Ewald argues that evolution favors diseases that can spread easily, and under modern conditions—especially once cleaner water and general hygiene have been factored in—that means milder ones. Unless it happens to emerge in an environment as extreme and rare as a World War I trench, a flu virus that kills in a day is limited in its ability to spread, and so loses out to the milder version that only makes you wish you were dead. “That’s why we’ve never seen that level of virulence again in flu,” said Ewald. “If a new virus were somehow both highly lethal and transmissible, the only way it could maintain both of those qualities is if transmission could somehow be easily feasible from sick people. That would rarely happen in nature.”
Thanks to new advances in biotechnology, however, nature is coming under the control of humanity. And that changes the game entirely.
BIOTECHNOLOGY
Engineering a Killer
In the darkened ballroom of the Mandarin Oriental Hotel in Washington, D.C., some of the finest minds in government are debating how to stop the end of the world. They’re here to take part in a daylong tabletop exercise put on by the Johns Hopkins Center for Health Security, an academic nonprofit focused on biosecurity. The participants—which include former Senate majority leader Tom Daschle and Dr. Julie Gerberding, who headed the CDC during SARS—are playacting the role of presidential advisers convened to respond to a fictional outbreak of a new virus. The scenario on the table has been meticulously crafted by infectious disease experts, and details are doled out to the participants via reports from a Hopkins staffer who plays the role of the national security adviser and through fictional cable news segments that are shown on a TV in the ballroom. It might sound like a very Washington game of pretend, but such tabletop exercises offer officials an invaluable opportunity to test out answers to unprecedented crises—like the global disease pandemic about to strike.
The outbreak begins when groups of people in Germany and Venezuela begin to fall ill with a disease that has no known cause. That sets off alarm bells that grow louder as the disease erupts in new countries, including the United States. Just as they did with SARS, scientists soon manage to identify the mysterious virus causing the outbreak. They name it Parainfluenza Clade X to indicate that it is a member of an unknown branch, or clade, of the parainfluenza family. The news is surprising—parainfluenzas usually cause nothing worse than the common cold, yet this new Clade X spreads as efficiently as the flu and initially kills more than 10 percent of its victims. It is impervious to existing antivirals and vaccine. There is no effective treatment.
Up to this point the simulation has consciously echoed past disease outbreaks like SARS or the 2009 H1N1 flu pandemic, although with what appears to be a much more deadly virus. But the exercise takes a turn when the participants learn that Clade X did not emerge naturally from the wild like SARS, the result of a viral encounter between an unlucky animal and an unlucky human. Clade X, scientists discovered, was created in a lab by members of an environmental extremist group with the goal of immediately and drastically reducing what they view as human overpopulation. With the use of cutting-edge genetic engineering tools, a run-of-the-mill parainfluenza strain was spiked with the neurological virulence genes of a Nipah virus, a real-life pathogen that emerged in Southeast Asia in the late 1990s and can kill as many as three-quarters of its victims during its rare outbreaks.
As the exercise unfolds the participants at the Mandarin Oriental debate whether the United States should close its borders to slow the spread of the disease, and where to concentrate increasingly scarce health resources. But their decisions ultimately make little difference. While we saw in the last chapter that nature demands a virus choose either contagiousness or virulence, the makers of Clade X have used biotechnology to override evolution, ensuring that their creation can retain both the transmissibility of a parainfluenza virus and the deadliness of Nipah. It is the perfect bioweapon: a virus that spreads like the common cold and kills like Ebola. The world is defenseless.
By the end of the Hopkins exercise, twenty months into the fictional pandemic, 150 million people worldwide—2 percent of the global population—
have died from Clade X. The global economy has collapsed under the strain, with the Dow Jones average down 90 percent, U.S. GDP down 50 percent, and unemployment at 20 percent. Washington is barely functioning—the president and the vice president are both ill, and one-third of Congress is dead or incapacitated. Former Missouri senator Jim Talent, who is playing the secretary of defense, puts it starkly as the simulation concludes and the lights come up at the Mandarin Oriental. “America,” he tells the audience, “was just wiped out.”1
The Clade X exercise, which took place in May 2018, was the latest in a series of pandemic war games put on by the Center for Health Security. The scenarios are always worst case, which is the point. One earlier exercise, called “Dark Winter” and staged by Hopkins in 2001, simulated a smallpox bioterror attack on the United States. The timing—just a few months before the 9/11 attack—was eerily prescient, as if the organizers had foreseen how the threat of terrorism, including bioterrorism, would come to consume the U.S. government and public in the years to come.
At their best these exercises provide a way to road-test how we might react to health threats that loom just over the horizon. In 2001 that meant the possibility that terror groups like al-Qaeda might get their hands on a sample of smallpox virus and release it into the world as an infectious weapon, seeking to sicken and kill as many people as possible. Such conventional bioterror remains a real threat—al-Qaeda and more recently ISIS have both sought to find and weaponize existing viruses like smallpox.