Deadliest Enemy: Our War Against Killer Germs

by Mark Olshaker

infectious disease is the deadliest enemy faced by all of humankind. True, infection is far from the only type of illness that affects each of us, but it is the only type that affects us collectively, and sometimes on a mass scale. Heart disease, cancer, even Alzheimer’s, can have devastating individual effects, and research leading to cures is laudable. But these diseases don’t really have the potential to alter the day-to-day functioning of society, halt travel, trade, and industry, or foster political instability.

The what: in one cluster, Pneumocystis carinii pneumonia (PCP)—a rare parasitic infection that causes a life-threatening pneumonia and usually occurs only in people with compromised immune systems.

“The microbe that felled one child in a distant continent yesterday can reach yours today and seed a global pandemic tomorrow.”

As epidemiologists, we have two goals. The first is to prevent. When that is not possible, the second is to minimize disease and extended disability.

We have several important weapons for prevention: sanitation, including safe water and food and the safe removal of human and animal feces and urine; vaccination; and anti-infectives, which can minimize disease, disability, and, potentially, infectiousness. Vector control is critical for reducing disease-transmitting mosquitoes, ticks, and flies.

In a 2015 TED Talk, Bill Gates asserted, “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.

But we’ve actually invested very little in a system to stop an epidemic. We’re not ready for the next epidemic.”

There are only four events that truly have the power to negatively affect the entire planet. One is all-out thermonuclear war. Another is an asteroid striking earth. The third is global climate change. And the fourth is infectious disease.

a pandemic spreads around the world and lasts for an extended period of time. It does not hit just one locale, leaving all others with the ability to come to its aid.

A pandemic hits many locales simultaneously, all of them needing emergency assistance. It has a rolling effect as it hits first individuals, then civil authority, then business, then interstate or international commerce or both. The effects are immediate and devastating, the consequences long-term.

When everyone is involved in a pandemic, no one has extra help or supplies or food or medicine to send around, unle...

When a rolling global pandemic takes its toll on the working population of a city in Asia, for example, the products and supplies that come from that city—and perhaps nowhere else—that we need to respond to a rapidly growing pandemic will not be available.

No amount of money can buy something that doesn’t exist.

The second priority is to prevent high-impact regional outbreaks, such as Ebola and coronavirus infections including MERS, and the possible return of SARS and Zika as well as the other mosquito-borne diseases that continue to have such a devastating impact on the world’s poor and that disrupt national economies and governance.

We’re pretty much constantly surrounded by other people. Most of the time we encounter the same people every day, but we also see some different people every day.

Viruses are not, strictly speaking, alive, but neither are they inorganic. They exist in a sort of intermediate netherworld, lying in wait until they can hijack the reproductive mechanism of a living cell and get it to churn out copies of the virion by the millions.

Zaire Ebola, the strain that caused the 2013–15 West African epidemic, is efficiently deadly to humans, with anywhere from one-third to one-half of the victims dying. Reston Ebola, the strain that played the lead in The Hot Zone, Richard Preston’s 1994 bestseller, was fatal to primates but left humans virtually untouched.

As civilizations grew and progressed, so did the speed and impact of infectious diseases. Yersinia pestis bacteria—the Black Death bubonic and pneumonic plague that wiped out between a quarter and a third of the European population in the fourteenth century—took only a decade to spread across Europe and continued to be deadly for more than a century.

All of these disruptions in governance can lead to major catastrophes in public health.

A pandemic can shut down regional, national, or even international commerce, which in turn can lead to economic chaos, which in turn can lead to destruction of confidence in unstable governments.

If a government’s authority is shaky to begin with, the stress of a pandemic can lead to a failed state, which in turn can lead to anarchism and terrorism.

In the three West African nations affected by the 2014 Ebola outbreak, crops were not harvested, schools shut down, borders closed, and the Peace Corps removed 340 volunteers. Because they were unable to receive medical care during the outbreak, almost as many people died from HIV, tuberculosis, and malaria infections as died from Ebola.

that Marburg filovirus—a close cousin of Ebola—resides in fruit bats that live in locations such as Kitum Cave in Kenya’s Mount Elgon National Park.

It’s important to note that reservoirs need not be animals, or even alive. A reservoir can be a plant, a body of water, or any other host in which the pathogen can multiply and survive while it waits for its next spread.

The other is pandemic influenza, which occurs when a new flu virus emerges out of the animal world through mutation or reassortment so that it can infect and be transmitted by humans. Generally, seasonal flu is a remnant of a strain of the flu virus that once caused a pandemic.

During the 2009–10 H1N1 flu pandemic, the number of cases of the second, critical wave peaked in the United States in October 2009.

Zaire Ebola, the same strain that caused the virus in west-central Africa, could be transmitted via the respiratory route from pigs to monkeys, both of whose lungs are very similar to those of humans.

This was the time of year when the influenza sleuths are on high alert for new strains to emerge out of China and the Far East—the world’s largest concentration of humans living in close contact with enormous populations of pigs, poultry, and aquatic birds such as ducks and geese. These avian species are the natural reservoir for the virus.

By May, it had been determined that two of the prime reservoirs for the disease were masked palm civets and ferret-badgers, native to the Guangdong region and sold in local markets there as food. So the transmission to humans was probably similar to that of Ebola when locals in rural west-central Africa ate infected bushmeat. Further research indicated that the civets and badgers had most likely caught the virus from bats sometime in the months to years before the outbreak.

What eventually stopped the spread was not high-tech medicine, since there wasn’t any specific treatment for SARS. Instead it was implementing impeccable infection control, including isolating patients and making healthcare workers wear protective gear, and then intensive follow-up of both healthcare workers and community contacts, with immediate isolation if they showed any early symptoms of SARS.

For reasons we still don’t completely understand, certain individuals with coronavirus become “superspreaders.”

In the public health–infectious disease world, we worry most about diseases that have high mortality rates and that can be effectively transmitted via the respiratory route—in other words, killer diseases that you can catch just by being in the same air space with an infected person or animal.

The bad news was that it appeared to have a mortality rate even higher than that of SARS—somewhere between 30 and 40 percent—prompting some in the public health community to refer to it as “SARS on steroids.”

The somewhat better news was that it didn’t seem to transmit between people very well. To catch it, you had to have close extended contact with an infected person.

Zika was first detected in a rhesus monkey in the Zika Forest in Uganda in 1947 and then was isolated in a ten-year-old girl in Nigeria in 1954.

As far as pandemic potential is concerned, the most dangerous places on earth are anywhere people, birds, and swine are crowded close together in large numbers—the food markets of China and Southeast Asia, for example, or the industrial farms of the American Midwest.

Unlike most seasonal influenza virus strains, the 1918 H1N1 strain was anti-Darwinian: Rather than claiming the old, the infirm, and very young children—those with weak or underdeveloped immune systems—this one killed off the strongest and fittest, as well as pregnant women, in disproportionately high numbers, causing a “cytokine storm” in healthy individuals, as we described in chapter 5.

In New York City, the pandemic left 21,000 children orphans. It was so widespread that the disease peaked in Boston and Bombay at the same time. In some parts of the world, according to John Barry, the death rate was so overwhelming that it was impossible to bury all the corpses. At one time or another, almost every city in the United States ran out of coffins.

Ordinary civic and commercial functions were not being carried out because so much of the workforce was sick or dead. Some sick people starved to death, not because there was a food shortage but because so many people were afraid to come in contact with them. Unlike a virus such as Ebola, which is not communicable until the victim starts having symptoms, with influenza, you’re contagious before you even feel sick.

Amid the annual seasonal flus that have crept up each year since then, there have been three influenza pandemics: 1957 H2N2 Asian flu; 1968 H3N2 Hong Kong flu; and 2009 H1N1 swine flu.

We now realize that there are two distinctly different patterns of influenza pandemic cases. One is what we saw in the 1918 and 2009 pandemics, where severe illness and deaths fall disproportionately on young adults.

Hospitals and healthcare systems will suffer most acutely. As long as the number of cases doesn’t exceed the capacity of our intensive care units, these units will be able to help patients who present with severe influenza symptoms. But what if the number of severe cases goes up by 30 percent?

But what if we had twenty or thirty 9/11s or Hurricane Katrinas all at once? We wouldn’t have the resources to handle that.

A catastrophic influenza pandemic will unfold like a slow-motion tsunami, lasting six to eighteen months.

In 1918, there were three distinct waves of disease over a two-year period, and that is what we could face again. So the only Hail Mary we would have is whatever we put in place beforehand.

At first, the doctors in the Shanghai metropolitan area think they’re just seeing late-season flu cases, but their patients don’t seem to be getting better.

In many cases, the victims report they had been sick for only a day or two, sometimes only hours. The majority of the victims are otherwise healthy young adults and pregnant women.

We are watching the early days of a quickly growing pandemic. No use closing borders; H7N9 has probably taken root in thirty or forty countries by now.

stay away from those who have influenza-like symptoms. Shelter in place if necessary. And if you have these symptoms yourself, or anyone in your family does, please stay home from work, school, or normal activities where you would interact with other people. Don’t travel via public transit either if at all possible; this includes planes, trains, buses, and taxis.”

an increasing number of healthcare personnel are too sick to work.