This is a critical point in history. Time is running out to prepare for the next pandemic. We must act now with decisiveness and purpose. Someday, after the next pandemic has come and gone, a commission much like the 9/11 Commission will be charged with determining how well government, business, and public health leaders prepared the world for the catastrophe when they had clear warning. What will be the verdict?
If I had read this book in more normal circumstances, I do not know how I would have responded. Perhaps I would have been slightly unnerved, but I think I would have been able to sleep soundly by dismissing most of it as alarmist. In fact, I did just this a few months ago, when I read Bill Bryson’s book on the body, and scoffed at his claim that another 1918-style pandemic was easily possible. Nowadays, however, reading this book is more depressing than anything. Those in the field saw this crisis coming from miles away, but few of us listened. The epidemiological community must feel rather like Cassandras right about now: uttering prophecies that nobody pays any attention to.
(As Osterholm was responsible for most of the ideas in this book, and as it is written from his perspective, I will refer to him as the author in this review.)
This book attempted to be the Silent Spring for infectious diseases. That it did not succeed in doing so is attributable just as much to human nature as to the book itself. Limiting the use of pesticides is fairly easy and relatively painless for most of us. But mobilizing the political will necessary to prepare for health crises in the hypothetical future—preparations that would involve a great deal of money and many institutional changes—is not such an easy sell, especially since we had been lulled into a false sense of security. As is the case with climate change, the dangers seemed so remote and theoretical that for most of us it was difficult to even imagine them.
After witnessing what this new coronavirus has done to our entire way of life in a few short weeks, I was quite disposed to take Osterholm seriously. And I think the entire content of the book—not just the warnings about a potential pandemic—are valuable. Osterholm turns his attention to a wide array of threats: Zika, AIDS, Yellow Fever, Typhoid, Malaria, Ebola, MERS. We are vulnerable on many fronts, and we are generally not doing much to prepare.
One example are the many diseases that are transmitted by mosquito bites. As modern transportation has introduced disease-carrying mosquitos into ever-more parts of the world, and global warming expands the geographic range of mosquitos, this will be an increasing concern. (Silent Spring may, ironically, have contributed to this problem.) Another worry is bio-terrorism. Now that we can see how paralyzing even a moderately lethal virus can be, imagine the damage could be inflicted by a genetically-modified virus. And the technology to edit genes is becoming cheaper by the year. We have already experienced bio-terrorism in the US on a relatively small scale with the 2001 anthrax attacks. This is just a taste of what is possible. According to Osterholm, a mere kilogram of the anthrax bacteria could potentially kill more than an atomic bomb. And it would be far cheaper to acquire.
But these are not even the biggest threats. According to Osterholm, we face two virtual certainties: another flu pandemic, and the imminent ineffectiveness of antibiotics.
The latter is quite terrifying to consider. Antibiotics are not easy to discover, and our arsenal is limited. Meanwhile, bacteria constantly evolve in response to environmental pressures, including to the use of antibiotics. It is inevitable that resistance to available antibiotics will increase; and this could have a profound effect on modern medicine. Even routine operations like knee-replacements would be unsafe if we did not have effective antibiotics. Slight injures—a scratch in the garden from a rose-bush—could result in amputations or even deaths. And yet, antibiotics continue to be widely prescribed for ailments they cannot treat, and given indiscriminately to livestock, which only accelerates the impending bacterial resistance.
The other major threat (as we are learning) is a pandemic. Now, Osterholm was not precisely correct in predicting the cause of the next pandemic, since he thought it would be a flu virus (though he does have a good chapter on coronaviruses, and in any case a flu pandemic is still just as possible). But he is certainly correct in identifying our many structural weaknesses. He notes our lack of stockpiles and correctly predicts a shortage in protective gear, face masks, and ventilators in the event of a pandemic. And though medical science has advanced a lot since 1918, in many ways we are even more vulnerable than we were back then, most notably because of our supply chains. Since so many of our medicines and medical equipment—among other things—are produced overseas, shortages are inevitable if trade is disrupted.
Osterholm is quite illuminating in his discussion of pharmaceutical companies and their incentives. As private businesses, they have little to gain by investing in preventative vaccines or in new antibiotics. In the former case, this is because vaccines have to undergo thorough testing and pass FDA approval, requiring millions in investment, only to face the prospect of uncertain demand once the vaccine hits the market. The case of SARS is instructive. After the disease was identified in 2002, companies rushed to make a vaccine; but when SARS receded, interest in the vaccine disappeared and pharmaceutical companies, cutting their losses, stopped work on the vaccine. We still do not have one.
The incentive system is just as ineffective when it comes to antibiotics. Finding new antibiotics is costly; and since there are currently many cheap antibiotics on the market, a new patented antibiotic probably would not turn a large profit. Besides, effective antibiotic stewardship requires that we use them sparingly, thus further limiting profit potential. Drug companies have much more to gain by creating products that would require continuous use, such as for chronic conditions. Letting the free market decide which drugs get developed, therefore, is not the wisest decision. Osterholm advocates the same approach as taken by government in weapons contracts, wherein the government essentially guarantees payment for any product that meets specifications.
Osterholm’s most ambitious idea for government funding is for a new universal flu vaccine. The flu vaccine we are all familiar with is based on old technology, and can only provide protection from a few strains of flu. Scientists essentially must guess what sort of flu will be circulating in a year; and they must do so every year. But Osterholm thinks that there is good reason to believe that a universal flu vaccine is possible, and recommends we devote at least as much money to such a vaccine as we devote to AIDS research. This seems very sensible to me, since the next pandemic will likely enough come from a flu virus.
I am summarizing Osterholm’s book, but I do not think I am doing justice to its emotional power. Now that I am living through the events that Osterholm predicts (in surprising detail), I feel a strange mixture of outrage and fear: outrage that governments did not listen when they had time, and fear that we will repeat the same mistakes when this current crisis is over. I cannot help but be reminded of another situation in which we comfortably ignore the dire warning of scientists: climate change. My biggest hope for the current crisis, then, is that afterwards we will be more willing to heed the warnings of these nerds in lab coats.
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