LIVE TO TELL THE TALE

As Rosenberg put it, “Epidemics start at a moment in time, proceed on a stage limited in space and duration, follow a plot line of increasing revelatory tension, move to a crisis of individual and collective character, then drift toward closure.

Even before Bill Gates talked about virus wars, bioweapons and bio – worlds, esteemed microbiologists Macfarlane Burnet and David White predicted in 1972 that “the most likely forecast about the future of infectious diseases is that it will be very dull.” They acknowledged that there was always a risk of “some wholly unexpected emergence of a new and dangerous infectious disease, but nothing of the sort has marked the last fifty years.” They probably anticipated that only historians will take an interest in pandemics. Times have changed. From herpes and legionnaires’ disease in the 1970s, to AIDS, Ebola, the severe acute respiratory syndrome (SARS), and now Covid-19, contagious diseases continue to threaten and disrupt human populations. Burnet and White were right, historians have indeed a lot to offer, mostly information on how humanity should not repeat the same mistakes.

It’s been a little over a decade since the world experienced its last pandemic, the 2009 H1N1 swine flu. Between the spring of 2009 and the spring of 2010, the virus infected as many as 1.4 billion people across the globe and killed between 151,700 and 575,400 people, according to the Centers for Disease Protection and Control. Having been through a pandemic in recent history, it seems reasonable to expect that government agencies in the world would be prepared for the next one. But there are some key differences between the 2009 swine flu and COVID-19, and the response to each of them.

“The 2009 H1N1 pandemic should have been a warning sign,” said Steffanie Strathdee, the Associate Dean of Global Health Sciences at the University of California San Diego’s Department of Medicine. “It didn’t end up being a pandemic that killed millions of people as we feared it would, but it should have been a wake-up call. By all serious estimates, COVID-19 is going to be a major killer.”

The 2009 flu pandemic was the second H1N1 pandemic the world had seen — the first being the 1918 Spanish flu, still the most deadly pandemic in history. The 2009 pandemic was caused by a new strain of H1N1 that originated in Mexico in the spring of 2009 before spreading to the rest of the world. By June of that year, there were enough cases that the World Health Organization declared the swine flu outbreak a pandemic.

In the U.S., between April 2009 and April 2010, the CDC estimates there were 60.8 million cases of swine flu, with over 274,000 hospitalizations and nearly 12,500 deaths — that’s a mortality rate of about 0.02%. The mortality rate for the novel coronavirus is much higher so far, around 2% (although the number will likely change as more people are tested). That may not sound like a big difference, “but when extrapolated, can mean millions more deaths,” Strathdee said. 

The 2009 flu pandemic primarily affected children and young adults, and 80% of the deaths were in people younger than 65, the CDC reported. That was unusual, considering that most strains of flu viruses, including those that cause seasonal flu, cause the highest percentage of deaths in people ages 65 and older. But in the case of the swine flu, older people seemed to have already built up enough immunity to the group of viruses that H1N1 belongs to, so weren’t affected as much.

Epidemics eventually resolve, whether succumbing to societal action or having exhausted the supply of susceptible victims. As Rosenberg put it, “Epidemics start at a moment in time, proceed on a stage limited in space and duration, follow a plot line of increasing revelatory tension, move to a crisis of individual and collective character, then drift toward closure.” This drama is now playing out with Covid-19, first in China and then in many countries worldwide. But historians have not limited themselves to description. Rosenberg argued that epidemics put pressure on the societies they strike. This strain makes visible latent structures that might not otherwise be evident. As a result, epidemics provide a sampling device for social analysis. They reveal what really matters to a population and whom they truly value.

One dramatic aspect of epidemic response is the desire to assign responsibility. From Jews in medieval Europe to meat mongers in Chinese markets, someone is always blamed. This discourse of blame exploits existing social divisions of religion, race, ethnicity, class, or gender identity. Governments then respond by deploying their authority, with quarantine or compulsory vaccination, for instance. This step generally involves people with power and privilege imposing interventions on people without power or privilege, a dynamic that fuels social conflict.

Another recurring theme in historical analyses of epidemics is that medical and public health interventions often fail to live up to their promise. The technology needed to eradicate smallpox — vaccination — was described in 1798, but it took nearly 180 years to achieve success. In 1900, health officials in San Francisco strung a rope around Chinatown in an attempt to contain an outbreak of bubonic plague; only white people (and presumably rats) were allowed to enter or leave the neighborhood. This intervention did not have the desired effect.

The human immunodeficiency virus (HIV) could, in theory, have been contained in the 1980s, but it wasn’t — and though the advent of effective antiretroviral therapy in 1996 dramatically reduced AIDS-related mortality, it did not end it. Striking disparities in AIDS outcomes persist, following familiar lines of race, class, and gender. As historian Allan Brandt famously concluded, “the promise of the magic bullet has never been fulfilled.”

Two familiar aspects of the response to epidemics are especially disheartening. First, stigmatization follows closely on the heels of every pathogen. Anti-Chinese hostility has been a recurrent problem, whether with plague in San Francisco in 1900, SARS in 2003, or Covid-19 today. Second, epidemics too often claim the lives of health care providers. Physicians died during plague outbreaks in medieval Europe, during a yellow fever outbreak in Philadelphia in 1793, during the Ebola epidemic in 2014, and in China now. Though such mortality reflects the willingness of health professionals to put themselves at risk to care for others, it can also indict governments that ask clinicians to confront outbreaks without the “staff, stuff, space, and systems” they need to be successful and safe.

History suggests that we are actually at much greater risk of exaggerated fears and misplaced priorities. There are many historical examples of panic about epidemics that never materialized (e.g., H1N1 influenza in 1976, 2006, and 2009). There are countless other examples of societies worrying about a small threat (e.g., the risk of Ebola spreading in the United States in 2014) while ignoring much larger ones hidden in plain sight. SARS-CoV-2 had killed roughly 5000 people by March 12. That is a fraction of influenza’s annual toll. While the Covid-19 epidemic has unfolded, China has probably lost 5000 people each day to ischemic heart disease. So why do so many Americans refuse influenza vaccines? Why did China shut down its economy to contain Covid-19 while doing little to curb cigarette use? Societies and their citizens misunderstand the relative importance of the health risks they face. The future course of Covid-19 remains unclear. Nonetheless, citizens and their leaders need to think carefully, weigh risks in context, and pursue policies commensurate with the magnitude of the threat.

The history of epidemics offers considerable advice, but only if people know the history and respond with wisdom, truly, we are going through a difficult journey and I hope we will live to tell the tale.

Meral Musli Tajroska – Psychologist, Consultant on violent extremism and radicalization, activist for gender equality.

Sources: The New England Journal of Medicine, LiveScience.

Image Credit: https://pixabay.com/photos/skull-dark-pirate-book-gun-death-1193784/