The Plague Cycle

by Charles Kenny

  It wasn’t just the US, of course: a French hospital treated someone for pneumonia at the end of December 2019. Blood taken at the time was later tested for Covid-19 and came back positive. France imposed a travel ban in mid-March.

  For a globally connected country, there may have been some benefit from imposing travel restrictions in early January or before, but no government acted that early. The first government worldwide to put in place an international travel ban related to Covid-19 was the Marshall Islands. It was introduced on January 24.40 (That said, small island nations are where short-term travel bans may make the most sense: New Zealand banned foreigners entering the country in mid-March 2020 when it had twenty-eight confirmed cases of Covid-19, and put the whole country in lockdown soon thereafter. When that was combined with a vigorous test-trace-isolate strategy for suspected cases, the initial outbreak was rapidly controlled.)41

  Worse, travel bans remained in place long beyond any hope of efficacy. US bans were in place through the first half of 2020 despite the fact that the country had more confirmed cases of Covid-19 than any other for most of that time.

  Banning travel usually simply complicates authorities’ response to new disease threats—slowing the arrival of staff, supplies, and equipment to the countries battling an outbreak. Trade and collaboration, the transfer of goods, people, and ideas, are central to supporting health systems as well as developing and rolling out tests, treatments, and cures. We cannot respond effectively alone. We have to respond collectively.

  And in the longer term, there are reasons to think travel bans may further increase risk: a 2006 study of HIV-positive travelers from the UK to the US who were taking antiretroviral drugs at the time found that the majority traveled illegally rather than report their condition and risk either exclusion or exposure. Nearly a fifth of those surveyed stopped or delayed taking their antiretroviral medicines for fear of being searched on arrival in the US and their status being discovered.42 Not only did they increase their own health risks by doing so, given that antiretrovirals help reduce transmission of HIV, the suspension of self-treatment increased the risks to anyone they had sex with in the United States.

  Because of the importance of global connections to the quality of life, by far the largest economic cost of many recent global infectious threats, including Covid-19, has been the reaction of people and governments to the threat, rather than the disease itself. We’ve seen that the Black Death could kill off a third of the European continent and the immediate social and economic effect was surprisingly limited. And in an age where travel and trade were a very minor component of the global economy, regulations governing the movement of goods and people were comparatively minor disruptions to local economies. When Dubrovnik was introducing the concept of quarantine to the world, global trade was a few percentage points of output at most.

  But the extent of global integration today explains why even fairly insignificant disease threats can have such outsize economic impact. SARS killed fewer than eight hundred people, for example, but the economic cost of the global response was $140 billion.43 A World Bank estimate from a few years ago of the global costs of a severe global pandemic on the scale of the 1918 flu was that it might equal 5 percent of global gross domestic product, or $3 trillion.44 Covid-19 quickly showed that estimate to be wildly optimistic.

  And because we’re no longer in a Malthusian age, pandemics don’t even have the small silver lining of fostering equality. Research on epidemics over the last twenty years by economists at the International Monetary Fund suggests that poor people aren’t only more likely to die during an outbreak, they’re more likely to lose jobs and fall further behind the incomes of the rich.45

  Long-term exclusion and border controls were always a partially effective response to disease threats, at best. Today, they’re simply unaffordable—significantly counterproductive for health, ruinous for quality of life. The only solution is to use the immense innovative power and production capabilities that a globally connected and urbanized world has bequeathed to develop and roll out more effective responses.

  An approach based on rapid development and delivery of tests, treatments, and cures would significantly reduce future concern over new diseases, as it has in the past, even with the most deadly of infections. One result of the third plague pandemic (the latest appearance of the Black Death) is that every continent is a home to at least some wild rodents that carry the plague bacillus, including the Western region of the US, for example. There were four cases of human infection in America in 2012.46 But we haven’t put a wall along the eastern edge of the Mississippi to keep out potential carriers of the Black Death. Why? Because we have a vaccine, and (usually) the bacteria can be killed by a course of antibiotics.

  But the world still reacts poorly to new disease threats. Rather than deal with the risk before it emerges, through better sanitation and stronger health systems—or, as it happens, through better surveillance, screening, isolation, and research—we respond late and in panic, often with unnecessary acts of cruelty and abuse of human rights. Yet again in 2020 we learned that if we fail to improve on that performance in a globalized and urbanized world built on exchange, we pay an immense price.

  CHAPTER TEN Abusing Our Best Defenses

  I have also found that regressive behavioral disorder (RBD) in children is associated with measles, mumps and rubella vaccination.

  —Andrew Wakefield

  Advertisement for penicillin from Life magazine. (Credit: Science Museum, London. Attribution 4.0 International [CC BY 4.0])

  In August 2015, pediatricians in Recife on Brazil’s Atlantic coast reported a series of disturbing births involving microcephaly—children born with abnormally small heads. Microcephaly can lead to developmental delay, intellectual and learning disabilities, and problems with movement, hearing, and sight. The cause was a virus—Zika—transmitted by the Aedes aegypti species of mosquito. The Zika virus is a minor annoyance to those who aren’t pregnant; it merely causes joint pain, bloodshot eyes, and headaches. But at least this strain of the virus could cause severe damage to fetuses if it infected a pregnant woman. In response, the World Health Organization told pregnant women not to travel to countries where Zika was circulating. Further, it warned all women to avoid unprotected sex with men who’d visited countries with a Zika outbreak.1

  Rio de Janeiro was host to the Olympic Games in the summer of 2016, and there were increasingly heated calls to postpone the games or move them somewhere else. But there were good reasons to think the risk to visitors wasn’t that large; it was winter in the Southern Hemisphere and Rio was far from the epicenter of cases. The World Health Organization agreed the games should go ahead, and in the end, they did. Not a single case of Zika has been linked back to participants or spectators.2

  After the games, herd immunity (resistance to the spread of a contagious disease that results when a sufficiently high proportion of individuals in a population are immune to it) dramatically reduced spread: Brazil had 205,578 probable Zika cases in 2016 but only 13,253 by the end of July in 2017, all of which occurred prior to May.3 Since then, there’ve been few cases. This was an example where overreaction to a disease threat could have been far more damaging than the threat itself.

  But there was a time not too many decades ago when Brazil would have been completely free of risk. In 1955, using the insecticide DDT and other control techniques, Brazil eliminated the Aedes aegypti mosquito that transmits Zika. The country was re-infested by the end of the 1970s, and soon thereafter dengue fever—also transmitted by Aedes aegypti, and frequently the cause of joint pain, bleeding, and in serious cases shock—returned, too.4 Now there is a growing risk of the return of yellow fever, which uses the very same species of mosquito to spread. Worse, the insecticides commonly deployed against the Aedes aegypti have become less and less effective over the past ten years.5

  Aedes aegypti demonstrates that while we’ve made immense progress against old infections and their carriers ove
r the past eighty years, it hasn’t all been one-way. In an era when we’re racing toward eradication of some infections, we’re simultaneously abusing our existing weapons against communicable disease so badly that we create new threats. Millions still die prematurely from preventable diseases, in part because we’re underutilizing sanitation and vaccination while overusing antibiotics, and we’re intentionally developing new diseases as weapons.

  * * *

  Infectious diseases are still responsible for two-thirds of child deaths worldwide, around one-quarter to one-third of all deaths every year in poorer countries, and around one in twenty of all deaths in the United States in a normal year.6 Meanwhile, each year, malaria kills almost three times as many people as suffer murder or manslaughter, and diarrheal diseases cause eight times the global death toll from war.7 And while vaccines and immunizations may avert between 2 and 3 million deaths a year worldwide, 1.5 million children still die each year from vaccine-preventable diseases.8 This all suggests we have a long way to go in achieving the victories over disease that could be accomplished with existing tools and technologies.

  Look at sanitation: 1 billion people worldwide still defecate in public, 2.5 billion lack access to a decent toilet, and 800 million to clean water.9 Excreting in the nearest field because of inadequate or absent toilets has been a particular problem in densely populated India. In 1925, Mahatma Gandhi complained of his country that “the cause of many of our diseases is the condition of our lavatories and our bad habit of disposing of excreta anywhere and everywhere.” Surveys suggest that for every square kilometer in the country there are around 180 people going to the toilet outside—compared to less than half that in the next most feces-burdened countries of Haiti and Nepal. As a result, children regularly catch diseases of the digestive tract that leave them sickly and stunted. Sixty-five million Indian children under the age of five are extremely short for their age. That’s a higher proportion of stunting than in far poorer, less stable countries like the Democratic Republic of the Congo or Somalia.10

  Use a condom, sneeze into your arm, use the toilet, and wash your hands afterward—across the world, even people lucky enough to have access to the necessary infrastructure sometimes don’t follow these simple and powerful strategies. In flouting these prescriptions for a less infectious life, they harm themselves and create risk for the rest of us.

  And, sadly, the same applies to medical technologies: all too often people don’t avail themselves of the most effective treatments or—as bad—misuse those treatments. Not least, conspiracy theories have played a role in keeping the numbers of the unvaccinated higher than they should be, tragically delaying the total extinction of polio, to cite just one example. Making matters worse, some of those conspiracy theories contain an element of truth.

  * * *

  The history of anti-vaccination movements is as old as the technology itself. The 1867 Vaccination Act in the UK, which threatened imprisonment to parents who didn’t immunize their children, stirred particularly heated opposition, including the National Anti-Compulsory Vaccination League created in 1874 and the London Society for the Abolition of Compulsory Vaccination in 1879. William White, first editor of the London Society’s magazine Vaccination Inquirer, suggested that, from Jenner onward, the pro-vaccine camp had dissembled, lied, fabricated evidence, and hidden the truth about the efficacy and safety of vaccination. “Over and over again,” he said, “it has been proved that vaccinated patients dead of smallpox have been registered as unvaccinated.” Meanwhile, he argued, the elevated death rates of those who’d been given the vaccine had been covered up.11

  Eight years after smallpox vaccination finally arrived in Japan, an opponent claimed that only one out of ten doctors was in favor of the technique. Practitioners of traditional medicine viewed smallpox as the eruption of an innate poison present since birth rather than an infection.12 Again, in British India at the height of empire, some saw smallpox vaccination as a plot to poison the Hindu population. Gandhi, right on toilet use, was very wrong on vaccines:

  We are all terribly afraid of the small-pox, and have very crude notions about it.… In fact it is caused, just like other diseases, by the blood getting impure owing to some disorder of the bowels.… The superstition that it is a contagious disease [has] misled the people into the belief that vaccination is an effective means of preventing it.… Vaccination is a barbarous practice, and it is one of the most fatal of all the delusions current in our time.13

  The imperial authority’s response to local opposition was to limit vaccination campaigns to big cities, and even that on a fairly ad-hoc basis.14

  In the last few years, doctors who should know better have continued an assault against vaccination. In 1996, Dr. Andrew Wakefield, based at the Royal Free Hospital in London, met with a personal injury lawyer, Richard Barr. The lawyer represented parents of a number of autistic children and had been intrigued by Wakefield’s writing suggesting that there might be a link between the measles vaccine and Crohn’s disease (which causes abdominal pain, anemia, and fatigue). Barr wanted Wakefield to find a link between the measles vaccine and autism, and signed him to an $80,000 contract. Wakefield set to work on five of Barr’s clients, who, two years later, would be the majority of eight autistic children featured in an article he published in the Lancet medical journal. That article suggested there was a link between the measles-mumps-rubella vaccine and damage to the intestinal wall that allowed harmful proteins to reach the brain, causing autism.

  Wakefield didn’t compare autism rates among vaccinated and unvaccinated kids, nor name the proteins involved, nor how the vaccine might have caused damage to the intestinal wall. He also didn’t mention his contract with Richard Barr, or the fact that Barr had introduced him to his test subjects.

  In the years that followed, fourteen separate groups of researchers evaluated the records of more than six hundred thousand children, looking for an autism-vaccination link. Unlike Wakefield’s study, the results were convincing, clear, and repeated: no link existed. The Wakefield paper should never have been published and was eventually retracted. But it had an impact nonetheless. In the months after the paper came out, one hundred thousand parents in the UK chose not to vaccinate their children. In Swansea in the UK, one-third of the population went unvaccinated against measles and more than twelve hundred people were infected in an outbreak.15 Measles returned to France, where an outbreak led to five thousand hospitalizations and ten deaths. Vaccination rates fell in Ireland, too, and three children died as a result.16

  Dangerous ignorance with spillover effects quickly crossed the Atlantic. Talk show host Jenny McCarthy joined forces with US congressman Dan Burton of the House Committee on Government Reform to expose the supposed autism-vaccination link, and vaccination rates dropped. That has occurred even in some of the world’s most technologically literate places—Silicon Valley has seen some of the lowest child vaccination rates in the Western world. And in Los Angeles, thousands of parents sent their kids to private schools clutching “personal belief exemption forms,” which stated that the child hadn’t been immunized for fear of the health impacts that might follow.

  Health impacts have followed, but they’re from the children remaining unvaccinated. The schools, some of which had vaccination rates at below 40 percent (the level in South Sudan), have been the epicenter of outbreaks of measles.17 More than one-half of the 1,416 cases of measles in the US between 2000 and 2015 were among the small minority of people country-wide who were unvaccinated.18 Ten children died from a whooping cough outbreak in 2010 in California that spread thanks to reduced vaccination rates against that disease.19

  As in the UK, the anti-vaccination movement in the US was enabled by doctors. LA County pediatrician Jay Gordon advised holding off all immunizations until children are at least three on the grounds that parents had told him “their child has been harmed” by the measles-mumps-rubella vaccine. This while he admitted there was “no evidenced-based medicine, there’s no r
esearch saying that.” In neighboring Orange County, Dr. Bob Sears responded to the measles outbreaks by suggesting there was nothing to worry about: “Ask any Grandma or Grandpa (well, older ones anyway) and they’ll say ‘Measles? So what? We all had it. It’s like chicken pox.’ ”20

  In part thanks to Wakefield, Gordon, Sears, and their fellow travelers, vaccine denial has seen a strong resurgence worldwide. Forty-five percent of French survey respondents worry that vaccines are unsafe, alongside 31 percent in Japan. The global proportion is 13 percent—more than one in ten.21 If more people start acting on their fears and doubts, old infections could come roaring back.

  It isn’t just the vaccine deniers and their unfortunate children who’d be harmed: some people really can’t be given vaccines and they’d suffer the consequences from circulating infections. When she was two, Ashley Echols had a kidney transplant. As part of the transplant procedure, children are given drugs that suppress their immune response so that the body doesn’t reject the transplanted organ. As a result, she couldn’t complete the standard vaccination regimen. Had Ashley taken the chickenpox vaccine in her weakened state, she might have contracted chickenpox from it. And because of her suppressed immune system, the condition would have been life-threatening. But in June 2017, eleven-year-old Ashley was exposed to a child with chickenpox in Atlanta. So she was rushed to the hospital emergency room to be injected with immunoglobulin. Camille Echols, Ashley’s mother, shared the story on Facebook. She ended her post saying “She has been through so much already. And this was avoidable.”