Author: mac7800

Don’t Be Smart, Be Wise

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It’s said that intelligence is learning from your mistakes while wisdom is learning from the mistakes of others. For our final dive into pandemics and public health, let’s be wise. Let’s examine the historical mistakes of how pandemics and health crises were mismanaged and apply this wisdom when the inevitable next pandemic arises. There are 3 big take-aways.

1. Unknown Origins of Disease

Disease transmission types | Pre-Designed Photoshop ...

One of the biggest hurdles in combatting an emerging pandemic is not knowing what microogranism is responsible. As the cholera and AIDS pandemics demonstrated, this lacking knowledge leads to the circulation of various theories and speculations which soon become widely accepted as facts. Additionally, the mysterious origins of the disease prevents effective combative strategies against the spread. What type of pathogen determines whether it spreads through the air, water and food, on surfaces, or through a living vector. Without this initial understanding of what’s lurking in the shadows, the process of containing a pandemic is shut down before it can even get started. From this mysterious and therefore frightening origin stems the other hurdles in handling a pandemic. Accordingly, it’s key to establish the pathogen in question and sole means of transmission as early on in a pandemic event as possible.

2. Inability to Contain and Isolate the Sick

No Ebola found in quarantined African patient: Brazil

Another hurdle in combatting a pandemic is the ability to contain and isolate the sick from the healthy, especially those most vulnerable to infection. As the Spanish flu, SARS-CoV-1, and SARS-CoV-2 pandemics exemplify, a failure to isolate and contain the sick and asymptomatic carriers aids the pathogen in propagating rapidly throughout the population, no matter what other combative measures are attempted. Accordingly, once the origin of the disease is established, government and health services must effectively instill an isolation protocol proportional to the contagiousness of the disease. Furthermore, a major and often overlooked population with a high transmission rate is the military. The spread of the Spanish flu is largely attributed to the poor quarantine protocols of world militaries, through which the virus spread from citizens to military to new military to new country. Though it’s important to effectively contain and isolate disease within the general population, these efforts are undermined by decisions to allow various sectors and privileged classes to continue operating as they did prior to the pandemic in question.

3. Combatting Misinformation and Fearmongering

Toilet Paper Shortage 2 - EnviroNews | The Environmental ...

Finally, the most difficult to manage hurdle is combatting misinformation. Misinformation is a common obstacle, but it becomes especially dangerous at times of intense fear and mass panic, such as pandemics and other public health crises. As the AIDS pandemic greatly highlights, misinformation can spread rapidly, instilling itself in popular belief even after the actual health crisis is long over. From the start of a health crisis, it’s important for governmental bodies to establish open and honest communication with the public. When the public feels that governments are hiding things from them, it sows the seeds of distrust which cause the public to seek out other sources for their information. Americans’ trust in the federal government is always severely low, and this unhealthy relationship gets in the way of a society collectively uniting with the common goal of rooting out disease.

Let’s learn through history and the mistakes of those who came before us. By understanding and tackling these three major hurdles in combatting the spread of infectious disease, we can better manage the inevitable health crises of our future. Don’t just be smart. Be wise!

Cholera: Not Just The Poor Man’s Disease

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Often cholera is treated like a disease of the past, grouped together with the plague and smallpox which pose no serious modern concerns. While such an assertion is partially valid in that cholera no longer affects all of the modern world, unlike the plague and smallpox, it’s still prevalent and dangerous.

Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae. Infection can begin anywhere from 2 hours to 5 days after exposure to the bacterium. Symptoms usually include diarrhea, nausea and vomiting, and dehydration. Due to this symptom profile, cholera can quickly become deadly as the rapid loss of large amounts of fluids and electrolytes can result in death within hours.

In the past 200 years, there have been 7 cholera pandemics, the most recent being the 2016-2021 Yemen cholera outbreak. The third cholera pandemic, occurring between 1846-1860, is most frequently thought of when discussing the dangers of cholera.

In the 18th century, Great Britain was rapidly industrializing and by the 19th century, London was the largest city in the world due to mass migration from the countryside into industrialized towns. However, the city was unprepared for safely accommodating such large masses of people.

The city quickly became overwhelmed by human waste from the rapidly growing population who largely lived in the squalor of the overcrowded slums. Human waste soon overflowed into the gutters and the waterways. Until the COVID-19 pandemic, it was the worst outbreak in London’s history, claiming over 15,000 lives.

Illustration of London slum with subtitle 'A court for King Cholera'

At the time, the origin of the disease was unknown. The widely believed Miasma Theory held that cholera was the result of bad, stale air. Luckily one physician wasn’t so accepting of this theory. After systematically analyzing the people stricken by cholera in Soho, London, Dr. John Snow realized that all patients had one thing in common: a communal water pump. By removing the pump’s handle, the local outbreak ended.

While the solution of clean water seems like an easy fix, safe drinking water is a luxury in many parts of the world. 1 in 4 people worldwide don’t have access to safe drinking water with 6% of deaths in impoverished countries being the result of unsafe water. Each year, unsafe water is responsible for 1.2 million deaths. However, this issue is quickly hitting home in the United States as well.

Share of deaths from unsafe water sources - Our World in Data

Fresh water, “the oil of the 21st century” is quickly dwindling in parts of the United States due water stress from major population growth and changes in local climate. Since 2014, the citizens of Flint, Michigan are still without uncontaminated water.

While cholera is one example of diseases spread through contaminated water, other examples include dysentery, hepatitis A, typhoid, and polio. Furthermore, unsafe drinking water exacerbates malnutrition, resulting in childhood stunting which is also an important risk factor for death globally.

Number of deaths by risk factor - Our World in Data

For these reasons, maintaining and providing universal access to clean drinking water is a major global health emergency as the human population continues to grow and overwhelm Earth’s renewable resources.

 

 

 

PS. While researching, I discovered that there are two Cholera families in the United States dating to 1920. The last name of Cholera is most commonly found in India and 71% of Choleras live in Asia.

The AIDS Age of Misinformation

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On June 5 1981, the CDC published in its Morbidity and Morality Weekly Report a discussion of 5 cases of a rare lung infection known as Pneumocystis carinii pneumonia (PCP) in previously healthy gay mean. This is the first official report of what’s known today as Acquired Immunodeficiency Syndrome (AIDS).

Series of test tubes containing varying amounts of HIV particles and CD4 cells to depict the course of HIV infection.

AIDS is the final stage of Human Immunodeficiency Virus (HIV) infection. There are three stages of HIV infection: Acute Infection, Chronic Infection, and AIDS. During Acute Infection, people have flu-like symptoms while the HIV virus multiplies rapidly throughout the body attacking the highly important CD4 T-Cells of the immune system. Since HIV levels in the blood are very high, an individual in this stage is highly transmissible. During Chronic Infection, HIV continues to multiply but at such low levels that individuals may not have any symptoms. AIDS is the most severe stage of HIV infection as the severely weakened immune system leaves the body unable to fight off opportunistic infections-infections which usually pose only a harmless nuisance, such as the common cold. Once diagnosed with AIDS, individuals survive about 3 years without treatment.

It’s largely accepted that HIV evolved from the closely related Simian Immunodeficiency Virus (SIV), which spilled over to humans from Central African primates, further highlighting the dangers of the African bushmeat trade discussed in my previous post on the Ebola Epidemic. From Africa, HIV spread to the Western Hemisphere where it initially broke out in the gay community, whose lifestyle of casual, unprotected, multi-partner sexual activity allowed HIV to spread explosively. HIV transmits through bodily fluids-blood, semen, rectal fluids, vaginal fluids, and breast milk-meaning it can spread through unprotected sex, from mother to child via breast milk, through the sharing of drug needles, and from contaminated blood transfusions.

As of 2020, more than 36 million people worldwide have died of AIDS since the start of the pandemic. Although with proper treatment an HIV diagnosis is no longer a death sentence, there are still 37.7 million people worldwide living with HIV/AIDS as of 2020 who still experience the stigma of HIV diagnosis which dates to the pandemic’s beginning.

Since initial AIDS deaths were among gay men, the official name until 1982 for AIDS was ‘GRID’, or Gay-Related Immune Deficiency. With this early misstep, AIDS was quickly attached to what was, at the time, widely considered a sinful lifestyle. News broadcasts reporting on the pandemic used terms such as “gay cancer” and the “gay plague” as many openly blamed the afflicted, believing it was God’s punishment for living in sin. When it was shown that nearly half the people with AIDs weren’t homosexual men, homosexuals were further isolated as lepers capable of endangering “normal people” with their sin.

Figure 11: Misperceptions about HIV transmission held by small but notable minority of Georgians

This stigma was further bolstered by the misinformation on HIV transmission. Many thought, and still to this day believe that HIV can be contracted by touching an HIV-positive individual or surfaces the individual has touched. The responsibility for HIV misinformation is largely attributed to Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases, who speculated throughout the AIDS pandemic that close contact with AIDS-afflicted individuals could result in infection. The below interview of Dr. Anthony Fauci is from May 1983, where he speculates close contact is a method of HIV transmission despite the CDC’s certainty of all HIV transmission methods by January 1983.

The AIDS pandemic highlights the dangers of unfounded speculating and theorizing at times of high societal tension, especially during outbreaks of novel, deadly diseases. Such unproven speculations from trusted sources add fuel to the fire, resulting in long-lasting and impactful misinformation ingrained in society even decades later.

 

World War I and H1N1: The Dynamic Duo

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Today the flu virus is nothing more than a seasonal stressor for those who aren’t of vulnerable populations. However, the flu virus of today was not the same flu virus of the 1918 Spanish Flu Pandemic.

The 1918 Spanish Flu was an epidemic of H1N1 flu, a subtype of influenza A. This subtype was particularly infectious and lethal because of a rare combination of 8 genes which made an exceptionally unique natural-born killer. Unusually, the H1N1 flu had a characteristically high death rate amongst healthy adults, ages 15-34 years old. The high death toll was due to the efficiency of viral infection. Once the virus infected the lungs, it would overstimulate the immune system, causing a cytokine storm which encouraged the extensive migration of white blood cells to the lungs.

H1N1 influenza virus.jpg
H1N1 influenza A virus

While this may seem good thing, such an extreme immune reaction resulted in the destruction of lung cells and secretion of blood and mucus into the airway, causing difficulty breathing and suffocation. By the end of the pandemic in April 1920, nearly 500 million people worldwide had been infected and an estimated 17-50 million people died of the virus. The H1N1 flu virus alone lowered the United States life expectancy by more than 12 years. Accordingly, it is considered one of the deadliest pandemics in human history(1).

Soldiers from Fort Riley, Kansas, ill with Spanish flu at a hospital ward at Camp Funston
Soldiers sick with H1N1 flu in Camp Fuston’s hospital ward at Fort Riley, Kansas

Yet beyond the virulence of the H1N1 flu strain, the spread of the pandemic was largely due to World War I. Such an unprecedented large-scale war led to the drafting of millions of soldiers from countries across the world. Bringing together such a vast population in such unsanitary wartime conditions simply aided the virus’s spread.

Furthermore, the lack of abidance by a strict quarantine procedure within militaries did nothing to mitigate the spread of the virus. In the United States, when Camp Funston in Kansas was experiencing a rapid increase in H1N1 flu deaths, military officials transferred countless soldiers seeking refugee from the virus’s scourge(2). Instead, these soldiers simply brought the H1N1 flu virus with them to the military base they were transferred to. Additionally, soldiers from these infected military bases were being shipped across the Atlantic to fight on the warfront. In doing so, they continued to expose and spread the virus throughout the US military’s ranks and throughout the international militaries(3). However, the virus wasn’t limited to the militaries as the H1N1 flu quickly spread from the military bases to the surrounding citizenry.

Egon Schiele (1880–1918), Die Familie (The Family), painted a few days before his death, just after that of his wife Edith.

Though the greater context of World War I  is largely blamed for the H1N1 flu pandemic’s devastation, it was truly the ignorance and disregard of basic epidemiology principles which created the perfect storm that was the 1918 Spanish Flu.

 

 

SARS Insanity: Doing the Same Thing, Expecting Different Results

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Since 2020, the news is inundated with information on the continuing SARS-COV-2, or COVID-19 outbreak. A similar occurrence occurred in early 2003 with the original SARS-COV outbreak.

Pourquoi le SARS-Cov-2 est-il plus infectieux que le SARS ...
The spike protein trimers of SARS-COV and SARS-COV-2.

As the acronym indicates, SARS-COV originated as a strain in the coronavirus family, which is also home to the common cold viruses. The initial transmission of this strain was a zoonotic spillover from the bat population of the Guangdong province in southeast China (1). From there, SARS spread to Beijing, which at the time, had a population of nearly 13.8 million people. From Beijing, it quickly spread internationally, resulting in 8096 cases and 782 fatalities (2).

A SARS-COV molecule

The difficulty in tracking SARS was largely linked to its generic symptom profile nearly identical to the flu-fever, cough, chills, muscle aches, headache, and occasional diarrhea. The cause of SARS fatalities is it’s eventual progression to pneumonia (3).

The rapid spread of SARS internationally is accredited to superspreading: the transmission of a virus to at least eight contacts. Due to the initial lack of information on this deemed “atypical pneumonia” which spread through respiratory droplets that contaminated the air and surfaces, superspreading was most common amongst healthcare workers (4). One of the most notable being 64-year-old Dr. Liu Jianlun who, after checking into a Hong Kong Hotel for one night, infected seven people. Although he had less than eight contacts, one of the contacts was with a Canadian tourist who brought the virus with her back to Toronto where it infected 60 more people. Another three of his contacts brought the virus to Singapore, where it spread to more than 195 people. It’s estimated that nearly half of the world’s SARS cases could be traced back to Dr. Jianlun. Whilst it’s easy to simply blame poor public health initiatives and hospital safety protocols, healthcare workers wouldn’t have to contend with novel viruses without zoonotic spillovers (5).

SARS is largely believed to have spilled over from bats to humans in the Guangdong wet market. Wet markets are open-air markets which, in addition to selling domestic livestock, also sell wildlife. Although wet markets in larger cities are more hygienic, those of the smaller communities are known internationally for their unsanitary conditions. A recent analysis of 1725 game animals from wet markets across China found 71 mammalian viruses, including 18 potentially dangerous to humans (6). Wet markets aren’t unique to China as they’re also prominent in several other Asian, African, and Latin American countries(7).

UN: Live animal markets shouldn't be closed despite virus ...
An image taken at a Chinese wet market.

And just like the bushmeat trade of Africa, much of the Chinese population depends on the more than $73 billion wildlife industry(8). Furthermore, wet markets are historically engrained in Chinese culture. Chinese wildlife trade began in the 1970s after tens of millions of Chinese citizens died of starvation under Mao Zedong’s communist rule(9). Additionally, many of the goods sold are used in traditional Chinese medicine.

However, the further danger is the Chinese government’s seeming disinterest in creating long-term policy changes. Due to the SARS outbreak, wet markets were banned between 2002-2004(10). After everything settled down, they reopened until the ban following the avian influenza outbreak in 2014(11). Wet markets were once again banned in 2020 for the COVID-19 outbreak(12). Zoonotic viruses don’t disappear from wild populations during these temporary bans. Once the bans are lifted, the danger of zoonotic spillovers return. Furthermore, these bans likely diminish the potential immunity of the countless venders and marketers frequently exposed to these viruses. The continuous cultural significance of wet markets and the government’s lacking initiative to properly handle this complex public health issue create a fantastic breeding-ground for future zoonotic spillovers and novel outbreaks.