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CHAPTER 1
STOP EPIDEMICS WITH THE POWER OF SEVEN
We can end epidemics with seven sets of concrete actions proven over a century of epidemic response.
The enormous health and financial impacts of epidemics are made worse through human foibles like fear, denial, panic, complacency, hubris, and self-interest. But we can end epidemics by facing up to them and applying concrete actions I call "The Power of Seven": (1) ensuring bold leadership at all levels; (2) building resilient health systems; (3) fortifying three lines of defense against disease (prevention, detection, and response); (4) ensuring timely and accurate communication; (5) investing in smart innovation; (6) spending wisely to prevent disease before an epidemic strikes; and (7) mobilizing citizen activism.
I had my first lesson in epidemic forecasting back in 1975, when I was 24 years old. As a second-year medical student at the University of Rochester in upstate New York, I was fascinated by the stories one of my young professors, Dr. Steve Kunitz, told of his search for predictors of the bubonic plague outbreaks, which occurred every few years in the American Southwest. "Six hundred years after the Black Death killed half the population of Europe and swept through Asia and Africa to claim roughly 50 million lives worldwide, Native Americans and others in the Southwest endured sporadic outbreaks of this ghastly disease," Kunitz said. "They suffered abdominal pain, bleeding, blackening of the extremities, and other awful but classic symptoms. The question is: How were these Native Americans getting infected with plague?"
"Fleas on rats," somebody said.
"You're half right," Kunitz replied. "The disease came from fleas, but not rat fleas."
"Dog fleas?" another student suggested.
"Close," the professor said. "Prairie dog fleas hitchhiking on dogs. Native American families kept as many as ten domesticated dogs. These dogs often would hunt prairie dogs, picking up prairie dog fleas along the way."
We were perplexed. So where did the human plague come from?
Kunitz was a clever investigator. When he and a colleague visited the Navajo Reservation at Tuba City, Arizona, to discover how nature might signal when the next outbreak would occur, they began interviewing the locals. They suggested that clusters of dead prairie dogs ("die-offs") might carry a clue.
In class, we students learned that plague is caused by the Yersinia pestis bacteria, which is transmitted by the bite of an infected flea from a rat or other small rodent, like the prairie dog of the Southwest. The fleas that infested the prairie dogs came from rats that migrated on steamships from China, which suffered a plague epidemic in the 1860s. Over generations, the infected fleas migrated from ship rats to San Francisco squirrels, and the insects then made their way to the American Southwest. Kunitz and his colleague found that local domestic dogs regularly came in contact with prairie dogs and their fleas but rarely became visibly sick themselves.
Kunitz wondered whether the dogs might be getting a mild illness and developing antibodies to the disease. Could he measure that possibility by asking veterinarians to take blood samples when dogs came in for rabies shots? And what if the level of antibodies to plague among dogs meant that an outbreak of human plague was not far behind? "If both were true," he told us, "then regular testing of dogs could be used as an early warning alert for human plague."
Kunitz's research confirmed both of these hypotheses. Soon after, public-health officials began taking annual surveys of antibodies in dog populations. When dog antibody levels increased, community health representatives would spread the warning via local radio and TV and intensify education programs that teach people to protect themselves from fleas and recognize plague symptoms. The effort continues today, albeit with some modifications (such as sampling from coyotes instead of domestic dogs).
I was mightily impressed by this medical Sherlock Holmes. As a student, I had no idea how an epidemic disease could migrate around the world over centuries while occasionally jumping from its animal "host" to humans, inflicting death on tens, thousands, or millions of people. Nor did I have any inkling that, many years later, I would take on the challenge of preventing epidemics from starting.
Three Tales from Killer Diseases
The 1918 Spanish flu that sickened a third of the world's population almost a century ago still exists in weaker, seasonal strains today. For a tiny view of what could happen with a new pandemic, let's take a look at the moment when twentieth-century modernity was taking hold and World War I was winding down.
Based on clinical reports and genomic studies, scientists today believe that the influenza virus had been circulating within the armies of the World War for a long time — even years — before the pandemic of 1918–19. Like all influenza viruses, the Spanish version mutated. In the western trenches, that flu likely took hold among those who had no immunity to it and were living in filthy, wet, cold conditions. It then erupted in far-flung port cities: Freetown, Sierra Leone; Brest, France; and Boston, Massachusetts.
In the summer of 1918 in the U.S., the Spanish influenza first touched someone in Philadelphia. Americans were hoping for an end to the war and the return of their surviving fathers and sons. Many of the nearly 2 million citizens of Philadelphia flocked to theaters to see vaudeville, plays, and big events and concerts, exchanging occasional coughs. Nobody had paid attention to the fact that 8 million Spaniards were sick and dying from a strange new disease named the "Spanish influenza" or that people in Boston had come down with the same thing. The alarm bells were silent.
But by the time early autumn arrived, the coughing had spread the disease throughout the city. The coughed-upon developed fevers and pneumonia; the mortally ill suffocated because their lungs and organs collapsed, their bodies turning a hideous blue-black. By October 4, there were 636 new cases of the Spanish flu in Philadelphia; 139 people died. In less than a week, there were an astounding 5,531 new cases. In response, officials closed all the vaudeville and picture theaters, saloons, schools, and churches in the city. Most of the city's doctors had been sent to Europe to tend to soldiers while the flu was raging. Many remaining healthcare workers succumbed too. The most common treatment was whiskey, the stronger the better. But as whiskey ran out, frantic shoppers stripped pharmacy shelves bare. Medical care was in very short supply. Snake-oil salesmen advised patients to treat themselves with oil of balsam or to try "Munyon's Paw Paw" pills.
By mid-month, parents were so sick that they could not care for their children. Hospitals were so full that beds were set up in the armory. When volunteers showed up to hospitals to help, they could do little more than to carry away the dead. People died so fast that the coroner's office could not keep up with the demand for death certificates. Like some nightmare from plague-ridden fourteenth-century Europe, volunteers drove horse-drawn carts through the city streets, calling for people to "bring out the dead." Cemetery directors in Philadelphia raised prices for a plot by 50 percent and charged families an exorbitant $15 for the privilege of digging their loved ones' graves themselves.
In the streets, little girls jumped rope to a grim new rhyme:
"I had a little bird / and its name was Enza / I opened the door / And in flew Enza."
Before it was over, the Spanish flu of 1918 wiped out 13,000 people in Philadelphia and between 50 and 100 million worldwide. It remains the most deadly flu outbreak in history.
* * *
Gaëtan Dugas was a handsome, charming Air Canada flight attendant who claimed to have had more than 2,500 sexual partners. For years, epidemiologists considered him "patient zero" in the AIDS epidemic. Early researchers believed he contracted AIDS while in Africa. In his iconic 1987 history of AIDS, And the Band Played On, Randy Shilts portrayed Dugas as recklessly spreading AIDS through unprotected sex even after he was diagnosed. Dugas died from his illness in 1984.
As is the case with most epidemics, the first two decades of AIDS were rife with conspiracy theories about the origin of this other twentieth-century Black Death. Some people blamed smallpox immunization; others blamed a polio vaccine grown in chimpanzee cells; still others claimed that AIDS was a government-sponsored genocide weapon used against the black or gay communities. Over the last decade, however, gene sleuths have unraveled the mystery. Scientists have now found proof that five successful "species jumps" of the simian immunodeficiency virus (SIV) from primates to humans occurred in Africa during the last century. "Successful" means that the SIV virus adapted, through rapid mutation, to a form of human immunodeficiency virus (HIV) that would thrive and multiply in humans. The first species jump happened around 1910 in southeastern Cameroon. The biology of the HIV virus subtype tells us that it came from a chimpanzee, which a human probably killed to eat or barter as "bushmeat," ultimately igniting the AIDS pandemic.
From the first human infections in Cameroon, the HIV virus spread down the Sangha River — probably through sexual contact among those living near and traveling along the river — to the bustling city of Leopoldville (modern-day Kinshasa in the Democratic Republic of Congo). Leopoldville became the cauldron in which the pandemic slowly cooked over the next decades. In the early 1960s, following the end of the Belgian colonial government, the HIV virus was carried from the Congo to Haiti — most likely via Haitians returning from Africa after working for the colonial government. Around 1970, a single infected person or a container from a plasma-donation clinic brought the AIDS virus from Haiti to the U.S. and from the States to Europe.
Gaëtan Dugas certainly contributed to the spread of AIDS. But he was not patient zero. The HIV virus was already in North America when he contracted AIDS. AIDS had smoldered virtually unnoticed for more than 50 years in Africa before one strain passed into Western countries via Haiti, while other strains were carried from Africa to Asia and beyond. By 2014, the HIV virus had infected almost 78 million people.
* * *
The recent Ebola epidemic in West Africa also began with an animal. In late December 2013, a two-year-old named Emile Ouamouno had been playing in a hollow tree, grabbing and poking insect-eating bats. Shortly afterward, he grew seriously ill and died in a small Guinean village near the great rainforest where Guinea, Liberia, and Sierra Leone come together. His family mourned the little one with all the appropriate traditional rites, including holding and kissing his corpse.
There had been 22 previous Ebola outbreaks in Africa, all of which had been contained. In none did the caseload exceed 425, and there were rarely more than 50 deaths. Just months before the West Africa outbreak, experts had even declared Ebola to be a "dead-end event" because it burned out too quickly to spread very far.
But within weeks of little Emile's death, the Ebola virus that killed him had exploded into a three-country epidemic. By late 2015, it had infected nearly 30,000 people, killed more than 11,000, and touched people in Africa, Britain, France, Germany, Italy, the Netherlands, Norway, Spain, Switzerland, and the U.S. The conventional wisdom about Ebola had proven fatally wrong.
* * *
These three stories of devastating sickness — and others that I draw into this book — illustrate how murderous diseases erupt when a microbe jumps species from animals to humans, as in the cases of plague, AIDS, influenza, and Ebola, and then spread from human to human. The majority of new infectious diseases with pandemic potential actually result from these animal-to-human species jumps. Infectious-disease outbreaks also happen whenever humans are exposed to a virus, bacteria, or other microbe against which they have little or no immunity — just as Europeans, who had long endured smallpox, introduced the disease to the indigenous populations of the New World, very nearly exterminating them. Outbreaks also occur when a microbe to which humans have developed immunity mutates, as often happens with influenza.
A Gigantic Threat
Somewhere out there a dangerous virus is boiling up in the bloodstream of a bird, bat, monkey, or pig, preparing to jump to a human being. It's hard to comprehend the scope of such a threat, for it has the potential to wipe out millions of us, including my family and yours, over a matter of weeks or months. The risk makes the threat posed by ISIS (Islamic State in Iraq and Syria), a ground war, a massive climate event, or even the dropping of a nuclear bomb on a major city pale by comparison.
A new epidemic could turn into a pandemic without warning. (For definitional purposes, an "outbreak" refers to a localized epidemic — something that affects hundreds, sometimes thousands; an "epidemic" refers to an illness or infection that is in excess of normal; and a "pandemic" is an epidemic that occurs over a very wide area, crosses international boundaries, and touches thousands or millions.) It could be born in a factory farm in Minnesota, a poultry farm in China, or the bat-inhabited elephant caves of Kenya — any place where infected animals are in contact with humans. It could be a variation of the 1918 Spanish flu, one of hundreds of other known microbial threats, or something entirely new, like the 2003 SARS virus that spread globally from China. Once transmitted to a human, an airborne virus could pass from that one infected individual to 25,000 others within a week, and to more than 700,000 within the first month. Within three months it could spread to every major urban center in the world. And by six months, it could infect more than 300 million people and kill more than 30 million.
This is not alarmist science fiction or tabloid fear mongering. It is one of several highly plausible scenarios — and far from the worst — developed by infectious-disease specialists working with disease-modeling experts. Just ask Bill Gates, who funds a group that uses computer simulations to predict the spread of diseases. In an interview with Vox, Gates said, "The Ebola epidemic showed me that we are not ready for a serious epidemic, an epidemic that would be more infectious and would spread faster than Ebola did. This is the greatest risk of a huge tragedy. This is the most likely thing by far to kill over 10 million people in a year." He put the likelihood of a catastrophic epidemic at "well over 50 percent" in his lifetime. Gates's model estimates that a perilous virus, carried via cars, planes, ships, and trains, and spreading quickly in packed cities, could kill up to 33 million people in just over 200 days. Some experts put the potential first-year death rate at over 300 million people. To imagine what such a catastrophe would look like, imagine what happened in Philadelphia in 1918 occurring again, on a much larger scale, throughout the world. We would be in a world where scrappy, ravaged survivors struggle for life in a zombie-movie wasteland.
In the last century alone, smallpox killed 300 to 500 million people. The 1918 Spanish flu killed 50 to 100 million in a two-year period, and AIDS has taken 40 million lives since it was first recognized in 1981. The annual influenza outbreak still claims half a million people a year worldwide. The West African Ebola crisis took more than 11,000 lives — seven times the total of the 22 Ebola epidemics that preceded it. But widespread death isn't the only threat. For those who survive the initial infection, an epidemic leaves its own particular trail of disfigurement and disability. People who contracted smallpox suffered characteristic, sometimes horrific, scars along with blindness, limb deformities, and other disabilities. As a lifelong condition, AIDS and the side effects of treatment can affect nearly every body system from brain to bone.
In the early stages of a new epidemic — before it has been recognized or how it spreads has been determined, and before appropriate protection measures are in place — health workers die in high numbers. This was certainly true in the early phases of Spanish flu, AIDS, SARS, and Ebola. As with war, where common illness can take more lives than war injuries, epidemics sometimes take more lives from disruption of primary health care than from the epidemic itself. Because health workers are diverted to emergency response centers and health facilities are sometimes closed, epidemics can also disrupt routine public healthcare needs such as immunization, treatment of acute illness, and facility-based births.
(Continues…)
Excerpted from "The End of Epidemics"
by .
Copyright © 2018 Jonathan D. Quick, MD, and Management Sciences for Health, Inc..
Excerpted by permission of St. Martin's Press.
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