The Next Pandemic After This One and the Next One After That
I’m an epidemiologist, and this is what keeps me up at night.
In 2011, the movie Contagion did a superb and very realistic job of describing how the world would react if a pandemic occurred. In that movie, a colony of bats is disturbed by deforestation, and one of the bats makes its home above some pigs. The bad defecates over the pigs’ food, infecting the pig with a virus reminiscent of the Nipah virus, a zoonotic virus that already has caused outbreaks in Southeast Asia with a high death rate. The pig is then taken and cooked for food, and one of the food preparers is infected with the virus, passing it on to unsuspecting guests.
Throughout the film, different themes are explored, such as the misinformation via the internet spread by a character played by Jude Law. It explores the daily lives of ordinary people in Matt Damon’s character. Members of the Epidemic Intelligence Service and the scientists racing to get a vaccine ready are also portrayed. The virus in the movie has a 30–35% mortality rate, but only 1 in 12 people in the world become infected. That is 650 million infected and 227.5 million dead.
In the fictional world of that movie, society breaks down a bit, but not completely. States attempt to close their borders without much success. Some looting takes place. Matt Damon’s character worries his house is next after seeing his neighbor’s house being ransacked. Back at CDC, the political nature of the epidemic tests the limits of loyalty and patriotism. By the end of the movie, a rogue scientist tests the vaccine on herself, and a deus ex vaccinia ending gives everyone bracelets to show at shopping malls as the world returns to some sort of normalcy.
As we have seen over the last year, the world is a little more complicated than that.
Did You Learn Anything From 2009?
Back in 2009, in early April, I was noticing that something interesting was happening with the flu season in Mexico: It wasn’t ending. Friends and colleagues were telling me about health clinics full of people with influenza-like illness, and the laboratory indicators were also off. As I emailed friends and colleagues at CDC and other health departments, we all kind of started worrying that a worse-than-usual flu season was happening at a time when the flu season usually ended in North America. Certainly, all the indicators were there that our flu season from 2008 to 2009 was milder than usual. The only worrying thing at the time was the emergence of an H1 influenza virus that was resistant to Oseltamivir.
As it turns out, I was right. Or, rather, we were right. The flu season was not ending in Mexico and the southwestern United States because a novel influenza virus had emerged. By the end of 2009, we had it under control because we had a readily available laboratory test for it, a readily available set of vaccines, and because we — humans — had been exposed to other influenza viruses that gave us some protection. Moreover, the events of 2001 — the attacks on the World Trade Center, the Pentagon and Pennsylvania as well as the anthrax attacks by mail — all allowed for an infrastructure of emergency response to be well-funded and available in 2009.
Yes, it was a pandemic in the technical definition of the word (a worldwide epidemic), but it was rather mild when it came to morbidity (how many were sick) and mortality (how many died). That is not to say that the deaths were not tragic, though.
The 2009 H1N1 Influenza Pandemic was supposed to be the dress rehearsal for whatever would come next. Unfortunately, the institutional memory of that even faded quickly. Not even the MERS epidemics from 2012 to 2015 helped out institutions retain the lessons of how to handle a pandemic. By 2017, when the Trump Administration was in full power, much was done to defund and empty health institutions like the Centers for Disease Control and Prevention and the National Institutes of Health. And what can I say about the Administration’s relationship with the truth and with science?
By 2019, we had no public health relationship with China that was meaningful. Sure, many students came to the United States to study public health and take back that knowledge to help their booming populations. But there was no data sharing, no trust in allowing the United States “best of the best” in epidemiology to pay attention to a little cluster of pneumonia cases happening in Wuhan. By the beginning of 2020, that novel coronavirus — one for which we had no lab test, no vaccine and no previous exposure — revealed itself to the world, and the world was not prepared.
We all know how that is going.
The Coronavirus Pandemic Could Have Been Worse, Right?
Nevertheless, even with all the interruptions to our lives, the deaths and the people who are sick even months after being infected, this coronavirus pandemic has been somewhat “mild”. According to Johns Hopkins University, the death rates hover between 2% and 10%, depending on what country you are looking at and what data they are providing. That’s a far cry from the 30–35% that Nipah virus could cause. Also, about 227 million of the world’s 7.8 billion people have been reportedly infected. This is an underestimate, of course. Many of those infected do not show symptoms, so they do not get tested. Or they live in places where a test is not available or there isn’t a public health surveillance system ready to count them. Even if we double the cases, we don’t have the 1-in-12 rate from Contagion.
The question, then, is if there are worse things out there that could come at us as fast and furious as influenza, coronavirus or Nipah?
The answer is a resounding YES!
You see, Nipah has a cousin named Hendra, named after Hendra, Australia. Lilke Nipah, Hendra is one of those viruses that bats carry around for some reason. (Perhaps there was something to the tales about vampires?) In one outbreak, several horses became ill after coming into contact with bat guano (feces). The horses would later infect people who tried to help the horses through the disease. In that example, like in Contagion, the horses are intermediary hosts for a virus during a spillover event, an event where an animal virus spills over into the human population.
We had such a spillover event somewhere in Mexico in 2009, and previously with coronaviruses in 2002 and 2012. We had it again in 2019 with the current coronavirus, the cause of COVID-19. And we will have another one sometime in the future. The question is if we will be as lucky as we’ve been recently, or if the overcrowding, and environmental collapses we’re triggering by our own human activities will make things worse.
The Nightmare Scenario
That is what keeps me up at night: the nightmare of a situation in which many different factors of the world around us come together to cause mass death and devastation, maybe even an extinction level event (though the latter has a very low probability). Just look at how we in the United States reacted to the COVID-19 pandemic with division and even violence. Can you imagine that level of discord but with a pathogen that kills one-third of its victims AND manages to infect everyone? That’s 100 million+ dead in the United States alone.
Mix into that scenario a growing population with chronic diseases like overweight/obesity and everything that goes with having too many pounds on your body. Heart disease, lung disease, cancer, diabetes… All of those would combine to injure or kill more people than what the pathogen could do alone. Right now, about 40% of adults in the United States are obese. That means an increased risk of many things. Surely, the mortality (death) rate within that group would be much higher for any given infectious disease.
The world is also highly interconnected financially, which means that an economic slowdown in any of the major financial centers (United States, China, Europe, Brazil, Mexico, India) would send ripples across the globe. An economic slowdown alone leads to more disease and death because of the lack of access to affordable healthcare, the breakdown of the healthcare infrastructure, the inability to eat nutritious food, or overcrowding conditions that make communicable diseases easy to transmit.
Then there is climate change. Whether you believe in the role of human activity on climate change or do not believe, it doesn’t matter. It is happening, and it is leading to the change in habitats of things like bats and other animals that come bearing viruses and bacteria that are new to the human population. It is also causing mass migrations of people, and that trend will continue for the foreseeable future because once we got going with climate change, it became a rather large ship that will not turn around for decades even with 100% international collaboration. Move a bunch of people like that, and you’re also moving a lot of human disease due to the conditions of refugee camps or low-income housing.
There are more aspects to this scenario, but I think you get the point. You’ve read this far. You’re smart.
Okay, So What Do We Do?
Look, infectious diseases by themselves are not the entire story of why people die from them. Yes, things like the plague (Y. pestis) or Ebola are pretty bad on their own, but it is the environment and society that play a big part in what the outcomes will be. We’re seeing it with COVID-19, where the overcrowded, low-income neighborhoods are being hit harder than the wealthier suburbs, resulting in Blacks and Latinos in the United States having much higher rates of death and disease than their White counterparts even after adjusting (controlling for) many other factors.
As a result, we need to address those Social Determinants of Health and bring down the rates of obesity, diabetes, and other chronic conditions. We need to make sure that health disparities are addressed, so everyone can have the best chance at withstanding the next pandemic and the one after that. And, of course, we take the necessary steps to stop warming the atmosphere even if it is not us who are doing it. (It is.)
For the diseases themselves, we need international cooperation in disease surveillance and early investigation of clusters and outbreaks. Governments need to invest in the infrastructure necessary to keep a close eye on spillover events and make sure they are contained quickly. (That includes putting into place the legal and social frameworks for public health interventions that allow us to close down places where people would congregate without killing the economy.) And there needs to be a healthy investment in new drugs, vaccines and therapies to counter a worldwide epidemic.
Most of all, our educational systems around the world need to be reworked so that the population stops falling for the schemes of those who would sow the seeds of doubt in science for self-aggrandizement or to cause havoc. Children need to grow up thinking critically about the unending information laid out to them via the internet. Future adults must be equipped with all the tools they’ll need to make the best decisions and not be obstacles for public health but champions of it. Without public buy-in, there is no point to doing anything about the next pandemic.
Let us hope that the pandemic dress rehearsals we’ve had so far are enough to teach us a lesson on how to prevent the next one. Not likely, but let’s still hope.
René F. Najera, MPH, DrPH, is a doctor of public health, an epidemiologist, amateur photographer, running/cycling/swimming enthusiast, father, and “all-around great guy.” You can find him working as an epidemiologist a local health department in Virginia, grabbing tacos at your local taquería, or on the campus of the best school of public health in the world where he is an associate in the Epidemiology department. All the opinions in this blog post are those of Dr. Najera and do not necessarily represent those of his employers, friends, family, or acquaintances.