Medical historian Mark Honigsbaum speaks of a "century of pandemics" that stretches from the Spanish flu of 1918 to our Corona-related present. In an interview with Philipp Sarasin, he explains why we only ever prepare for the pandemic that has just passed.

  • Mark Honigsbaum

    Mark Honigsbaum ist Medizinhistoriker und Journalist und hat sich auf die Geschichte und Wissenschaft von Infektionskrankheiten spezialisiert. Er schreibt regelmäßig für The Lancet und ist Autor von fünf Büchern, darunter "Living With Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918" (2008). Sein jüngstes Buch, "The Pandemic Century: One Hundred Years of Panic, Hysteria, and Hubris" (2019) wurde von der Financial Times als "health book of the year" und von der New York Times als "Editor's Pick" ausgezeichnet. Derzeit ist er Senior Lecturer für Journalismus an der City, University of London.
  • Philipp Sarasin

    Philipp Sarasin lehrte Geschichte der Neu­zeit an der Universität Zürich. Er publizierte kürzlich "1977. Eine kurze Geschiche der Gegenwart" (Suhrkamp 2021) und ist Heraus­geber von Geschichte der Gegenwart.

Philipp Sarasin: Mark Honig­sbaum, you speak of the “century of pande­mics” for the period since the Spanish flu in 1918 and until today. One could, in a modern arro­gance, be a bit puzzled by this: After all, were not the socie­ties of the 18th and 19th centu­ries espe­ci­ally shaken by smallpox and cholera epide­mics, not to mention the Black Death in the 14th century?  Hasn’t modern medi­cine, in fact, pushed back epidemic dise­ases? In other words, what makes this last century so special? 

Mark Honig­sbaum: Thank you for your ques­tion. Of course, epide­mics and pande­mics have occurred throug­hout recorded human history, inclu­ding in the 18th and 19th centu­ries in the age of smallpox, plague and cholera. The diffe­rence is that whereas in the early modern period and up to the indus­trial revo­lu­tion and the advent of steam-powered machines, patho­gens with pandemic poten­tial moved at a fairly leisu­rely pace between conti­nents, in the 1880s this began to change thanks to faster and more exten­sive railway networks and the advent of steam-driven ocean liners. Coupled with the expan­sion in global trade and travel and other “globa­li­zing” forces in the 20th and 21 first centu­ries, this has made the world far more inter­con­nected than in the past, and also a far smaller place from an epide­mio­lo­gical and immu­no­lo­gical point of view. This process was already beco­ming appa­rent in the 1880s with the spread of plague from China to Hong Kong and North America (the Third Plague Pandemic) and in 1889-90, when the so-called “Russian influ­enza” pandemic was observed to spread rapidly from St Peters­burg and other Euro­pean capi­tals to New York within a matter of weeks. However, it was the First World War and the unpre­ce­dented move­ment of men, muni­tions and animals (prin­ci­pally horses) between North America and Europe, coupled with the world­wide outbreak of “Spanish influ­enza” in several inter­na­tional cities simul­ta­neously, that under­lined these new global epide­mio­lo­gical and immu­no­lo­gical reali­ties, although this only became appa­rent in retrospect.

PhS: In your book, you also mention the media…

MH: Yes, the other reason for my dating of the Pandemic Century from around 1918 is that the Spanish flu coin­cided with the rapid growth of news­pa­pers and inter­na­tional tele­gra­phic commu­ni­ca­tions, meaning that for the first time in history infor­ma­tion about novel disease outbreaks could be commu­ni­cated to dome­stic popu­la­tions ahead of the arrival of the patho­gens them­selves. Strictly spea­king, the first pandemic in which these new media tech­no­lo­gies played a signi­fi­cant social and cultural role was the 1889-92 Russian influ­enza pandemic, which followed the laying of the trans­at­lantic tele­graph cable between the United States and England and coin­cided with the boom in cheap, mass circu­la­tion news­pa­pers and the rapid expan­sion of Reuters and other news agen­cies employing the latest tele­gra­phic commu­ni­ca­tion tech­no­lo­gies. I may add that I wrote about this in my 2014 mono­graph, A History of the Great Influ­enza Pande­mics, but for reasons of length and to keep the narra­tive focussed, I omitted the Russian influ­enza from The Pandemic Century.  The result is a new modern, social reality in which infor­ma­tion about new patho­gens spreads faster than the viruses them­selves, disrupting biopo­li­tical discourses and the ability to manage pande­mics along rational scien­tific lines.

PhS: You do not simply describe “all” epi- or pandemic events of the past century in your Pandemic Century, but analyze in ten case studies exem­plary outbreaks of infec­tious dise­ases, from the Spanish flu to the current SARS-CoV 2 pandemic. Their common deno­mi­nator is perhaps their novelty, their novel appearance as “emer­ging dise­ases” – with the excep­tion, of course, of the plague, which broke out in Los Angeles in 1924… 

MH: As I indi­cate above, new dise­ases have occurred throug­hout history, but it is only in the late twen­tieth century that we began to employ the term “emer­ging infec­tious dise­ases” (EIDS) to describe the appearance of novel patho­gens with epidemic and/or pandemic poten­tial. The concept is closely asso­ciated with the work of the bacte­rial gene­ti­cist Joshua Leder­berg and the viro­lo­gist Steven Morse and an influ­en­tial 1992 Insti­tute of Medi­cine report, which defined EIDS as previously unknown afflic­tions of human popu­la­tions whose “emer­gence may be due to the intro­duc­tion of a new agent, to the reco­gni­tion of an exis­ting disease that has gone unde­tected, or to a change in the envi­ron­ment that provides an epide­mio­logic ‘bridge’.”

However, the term “emer­ging dise­ases” can be found in the medical lite­ra­ture as far back as the 1960s, and I would argue the concept can be traced to the influence of ideas of disease ecology on bacte­rio­lo­gical epide­mio­logy at the turn of the nine­te­enth century. You can see the seeds of these ideas in the writings of Theo­bald Smith, Karl Fried­rich Meyer, Charles Nicolle, and the French-born Rocke­feller rese­ar­cher René Dubos, whose book, The Bacte­rial Cell, had a tremen­dous influence on Leder­berg. Whether or not these visions were couched in expli­citly ecolo­gical language, it was as an outlook that tended to see disease as the result of tempo­rary biolo­gical imba­lances and distur­bances of natural equi­li­briums, rather than as some­thing that could or ought to be eradi­cated accor­ding to the bacte­rio­lo­gical para­digm of “one germ, one cure”. And it was a vision that was sympa­thetic to the role of both social factors and Darwi­nian perspec­tives, and that was prepared to embrace long evolu­tio­nary time frames.

PhS: I would like to return to the ques­tion of natural equi­li­brium below. But first, was the fight against infec­tious dise­ases in the 20th century not domi­nated by the “eradi­ca­tion” para­digm, for example in the eradi­ca­tion of smallpox in 1978?

MH: Yes, the “dream” of eradi­ca­tion, as I like to think of it, can be traced back to the birth of bacte­rio­logy in the 1880s and has been very effec­tive at unlo­cking funds for medical rese­arch and shaping poli­tical agendas, parti­cu­larly in the field of global health. But running along­side such eradi­ca­tio­nist perspec­tives there have always been other ideas and approa­ches – approa­ches which empha­sized the role of social and envi­ron­mental condi­tions in the emer­gence and re-emergence of patho­gens and the morbi­dity and morta­lity due to them. Indeed, one can trace a direct line from the ideas of the German physi­cian Rudolph Virchow, who saw medi­cine as prima­rily a social science, to thin­kers like René Dubos, who argued in the 1950s that complete freedom from disease was a “mirage” and that “at some unpre­dic­table time and in some unfo­re­seeable manner nature will strike back”.

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However, in the 1950s, under the influence of Cold War concerns about biowea­pons and efforts to eradi­cate old dise­ases like malaria and smallpox that were at conti­nual risk of “re-emerging”, the ecolo­gical ideas that led Dubos to empha­sise our funda­mental connec­tion to nature, and  what he called the “symbiosis of earth and human­kind”, were  subli­mated by figures like Alex­ander Lang­muir at the US Centers for Disease Control as a way of asser­ting the CDC’s autho­rity over disease surveil­lance. The result was that, come the 1970s and the global campaign to eradi­cate smallpox, led by the CDC and the WHO, biose­cu­rity discourses had more or less displaced these ecolo­gical ideas from main­stream medical thin­king. One of the conse­quences of this was to gradu­ally sow distrust of the eradi­ca­tio­nist agendas of leading biome­dical rese­arch orga­ni­sa­tions, such as the Gates Foun­da­tion. We can see the result of this in the pola­rized debates over the origins of SARS-CoV-2 and claims that virus is the result of a labo­ra­tory expe­ri­ment, or in the conspi­racy theo­ries that vaccines are part of a 5G plot to enslave the popu­la­tions of  Western demo­cra­cies. The tragedy is that at the very time we should be embra­cing deep ecolo­gical insights into the origins and trans­mis­sion of EIDS to human popu­la­tions and supporting Chinese efforts to iden­tify the inter­me­diary animal host(s) of SARS-CoV-2, we are para­lyzed by disagreements.

PhS: Against this back­ground: How do scien­tists actually reco­gnize some­thing new, namely an emer­ging disease, which is probably still comple­tely outside ever­y­thing they know, outside their patterns of looking at such a threat?

MH: As I see it, scien­tific know­ledge of emer­ging patho­gens is largely deter­mined by our previous expe­ri­ence. In essence, we are always prepa­ring to fight the pandemic just past. This expe­ri­ence not only shapes how we think about the factors and condi­tions that drive emer­gence events but the labo­ra­tory tech­no­lo­gies that are available to test our hypo­theses. That is why it is so diffi­cult to predict the next epidemic or pandemic threat ahead of time or to iden­tify these new patho­gens in a timely manner once they have emerged. We saw this most clearly in 1976 with the repeated fail­ures to iden­tify the bacte­rial cause of Legionnaire’s Disease, or the mistaken assump­tion in 2002 that what became known as SARS was due to an avian influ­enza virus. In the end, it took micro­bio­lo­gists thin­king outside the box to solve these riddles, through a process of trial and error. There is an old saying in medical rese­arch, usually attri­buted to Pasteur, that “fortune favours the prepared mind”. But in each example in my book, with the excep­tion of HIV/AIDS and to a lesser extent plague in Los Angeles in 1924, I show that it is precisely when scien­tists are not schooled in the stan­dard thought processes, or are novices to a parti­cular, specia­lized field of micro­bio­logy, that they are more likely to take note of chance obser­va­tions and think them signi­fi­cant. In other words, in the case of pande­mics “fortune favours the unpre­pared mind”. That is why it is so important for scien­tists and other experts to guard against hubris and culti­vate what Dubos described as “an alert­ness to the unexpected”.

 PhS: Basi­cally, these examples are a good illus­tra­tion of how science works, aren’t they? In my opinion, this is one of the most important insights that one can gain from your book: There is not simply “the” science that has “assured” know­ledge, but quite the oppo­site, it is only the best form of our not-knowing, our search for knowledge…

MH: Exactly. This is precisely why it was nonsen­sical for poli­ti­cians to talk about “follo­wing the science”, as if the science was settled or there was one scien­tific autho­rity we should follow. SARS-Cov-2, the coro­na­virus that causes Covid-19, is a classic example. Although coro­na­vi­ruses are respon­sible for a third of common colds and have long been known to cause disease in cattle and another animals, until the emer­gence of SARS 1 in 2002 coro­na­vi­ruses were not thought to pose an epidemic threat, much less a pandemic threat, to humans. To adopt the termi­no­logy popu­la­rized by the US secre­tary of defense Donald Rums­feld follo­wing the terro­rist attacks on the World Trade Center, SARS 1 was an “unknown unknown”. By contrast, we might say that SARS 2 was a “known unknown” – indeed, this is precisely why viro­lo­gists had been so concerned to survey the full host range of the virus in nature in  search of other SARS-like viruses before they could spill over and infect human popu­la­tions. Unfort­u­na­tely, even now, three years into the coro­na­virus pandemic, there is little consensus about the extent to which reco­very from infec­tion protects indi­vi­duals against subse­quent attacks and illness, or whether we will continue to see new vari­ants capable of evading the immu­nity curr­ently offered by vaccines. Nor, in January 2022, can we say whether the coro­na­virus is likely to become less viru­lent and settle into an endemic infec­tion, similar to seasonal flu.

PhS: It is quite inte­res­ting that you closely link the work of scien­tists rese­ar­ching new patho­gens under the pres­sure of a dramatic infec­tion outbreak with popular know­ledge and percep­tions and with the media envi­ron­ment. Science, in other words, does not take place in a vacuum – and of course, infec­tion outbreaks are also inten­si­vely accom­pa­nied or even shaped by media processes. In short, what role does the media play in an infec­tious disease outbreak?

 MH: As I see it, the media plays a pivotal role in trans­la­ting tech­nical scien­tific terms into lay discourse and advan­cing or under­mi­ning the public under­stan­ding of science. This is parti­cu­larly the case at times of pandemic crisis when it becomes crucial for the public to take on board scien­tific know­ledge about the risks posed by new patho­gens and adjust their beha­vior so as to reduce deaths and prevent health systems from being over­whelmed. At the heart of this trans­la­tional process is meta­phor. Meta­phors are not merely rheto­rical flou­rishes but actually “create” or consti­tute social, cultural and psycho­lo­gical reali­ties for us by invi­ting us to act upon the world in parti­cular ways. In this pandemic, for instance, we have been conti­nu­ally exhorted to “flatten the curve” or to see vaccines as “silver bullets” that will bring the “war” against the virus to a speedy conclu­sion, permit­ting the resto­ra­tion of normal social life. But while meta­phors can help shore up social cohe­sion and direct our beha­viour, to the extent that they simplify or distort complex scien­tific and social reali­ties, they are a double-edged sword.

The media is also a “sensa­tion engine”, ampli­fying gaps in scien­tific know­ledge and exag­ge­ra­ting infor­ma­tion – and misin­for­ma­tion – for commer­cial gain. We saw this, most clearly, in the 1980s when HIV/AIDS was mislea­dingly labelled a “gay plague” thanks to early epide­mio­lo­gical studies suggesting that homo­se­xuals were at greater risk of contrac­ting and commu­ni­ca­ting the disease. And we also saw it during the 1930 parrot fever pandemic and the outbreak of Legionnaire’s Disease in Phil­adel­phia in 1976. In retro­s­pect neither outbreak was parti­cu­larly serious, but both leant them­selves to  media “scare stories” – stories that were fuelled by uncer­tainty as to the respon­sible micro­bial agents and the deaths of elderly and revered segments of the popu­la­tion. Of course, today the Internet and social media makes this process far more unruly.

PhS: You often use the word “hysteria” in this context, which asto­nished me a bit: Hysteria as an exag­ge­rated reac­tion (and, inci­den­tally, connoted as female) to a looming danger. But is it not quite legit or at least under­stan­dable to become “hyste­rical” in the face of plague or Ebola? And can we not observe at present that many are rather care­less in dealing with the threat of COVID-19, or are simply tired of Corona – and not “hyste­rical” at all?

 MH: When employing emotion terms, such as “hysteria”, or “dread” and “panic”, there is a danger of being overly analy­tical. Hysteria and other emotion terms, whether impli­citly or expli­citly gendered female, are there in the original source mate­rial – hence Paul De Kruif’s charac­te­riza­tion of US news­paper reporting of parrot fever as “one of our American hyste­rias”. De Kruif, by the way, should know: through his contri­bu­tions to maga­zines like Ladies Home Journal and his popular science writing, he helped propa­gate several “germ panics” in America the 1920s and 1930s.

Of course, when faced with a deadly disease that is spre­a­ding rapidly from person to person with no pros­pect of preven­tion or cure, panic and hysteria may be perfectly rational responses. But as we saw with the stig­ma­tiza­tion in the 1980s of homo­se­xuals and other supposed “carriers” of HIV, such as hemo­phi­liacs and Haitians, more often these emotions are counter-productive. That is why in The Pandemic Century I focus on the role of medical know­ledge and scien­tific tech­no­lo­gies, and the role of the media and public health, in regu­la­ting “appro­priate” emotional responses.

A good example of these “tech­no­lo­gies of dread” are epide­mio­lo­gical disease models that seek to track the repro­duc­tive rate of the coro­na­virus and predict the likely impact on hospi­ta­liza­tions and deaths. I have no doubt, for instance, that had Impe­rial College not shared a disease model in early March 2020 predic­ting that without social distancing and other strong suppres­sive measures, Britain risked 250,000 deaths from Covid-19, the British govern­ment would not have ordered a lock­down as early as it did, or have been able to count on the same level of public compli­ance. But now that we are seeing much milder illness from Omicron and people are better informed about the risks, we can see that this fear is dissipating.

PhS: We have not yet discussed the most important aspect of the “novelty” of emer­ging dise­ases, namely the ques­tion of why they occur at all. Is the impres­sion correct that there are more and more new infec­tious dise­ases – and why is that? What are the factors that cause more and more new dise­ases with pandemic poten­tial to emerge? 

MH: In 1972, the Austra­lian immu­no­lo­gist and Nobel prize winner Frank Macfar­lane Burnet wrote that “the most likely fore­cast about the future of infec­tious disease is that it will be very dull”. Burnet was mistaken. Between 1940 and 2004, rese­ar­chers iden­ti­fied 335 emer­ging infec­tious disease events, with a peak inci­dence in 1980, in other words around the time of the iden­ti­fi­ca­tion of AIDS. Moreover, to judge by the recent run of pande­mics and epide­mics the process does indeed seem to be spee­ding up. For instance, the early noughties were marked by a series of outbreaks of H5N1 bird flu. This was followed, in 2009, by the emer­gence of a novel H1N1 swine flu virus in Mexico. Though the H1N1 swine flu virus was nowhere near as severe as the 1918 Spanish influ­enza, or the 1957 and 1968 influ­enza pande­mics, it spread rapidly world­wide, beco­ming the first pandemic of the 21st century. Moreover, in the past 15 years scien­tists have iden­ti­fied 500 new SARS-like coro­na­virus in bats. Based on the current rate of disco­very, it is esti­mated there may be as many as 13,000 more coro­na­vi­ruses waiting to be disco­vered. Of course, this disco­very process is only possible due to better epide­mio­lo­gical and viro­lo­gical surveil­lance and new genomic tech­no­lo­gies that enable us to iden­tify muta­tions and viral recom­bi­na­tions in ways that would have been impos­sible in previous centu­ries. So, we need to be cautious as to whether this repres­ents a real pheno­menon, as opposed to being an arte­fact of scien­tific technologies.

PhS: But isn’t also true that humans are incre­asingly coming into contact with wild animals and ther­e­fore also with patho­gens that previously existed only in animal reser­voirs? Why is that signi­fi­cant and what should we do about it?

MH: That’s correct. We know that two-thirds of emer­ging human patho­gens are zoonotic and that, of these, 70 percent origi­nate in wild animals such as bats, rodents and wild water­fowl. It would ther­e­fore greatly aid pandemic prepared­ness and response if we had a better gauge as to what patho­gens are out there in wild animal reser­voirs and which have the poten­tial to “spill over” and trigger epide­mics and pande­mics. To achieve this, we urgently need to streng­then public health surveil­lance with the aim of deli­ve­ring a globally robust early warning system for pneu­mo­nias of unknown aetio­logy. But although the World Bank and World Health Orga­niza­tion have  been discus­sing how to reinvi­go­rate the Global Prepared­ness Moni­to­ring Board and the WHO recently estab­lished a $100 million “hub” for pandemic intel­li­gence in Berlin , progress has been slow to non-existent. The point is we already know that the globa­liza­tion, coupled with the growing demand for animal protein and fractal farming on the edge of rain­fo­rests, is making these emer­gence events more likely, and that we despera­tely need to expand labo­ra­tory capa­city and invest more in front­line health­care if we are to have a chance of respon­ding more rapidly and redu­cing the burden from EIDS in future. Such insights are important because they under­line the way in which infec­tious disease is part of an ecolo­gical web that is itself influenced by a constel­la­tion of economic, social and envi­ron­mental factors, and that it’s when our world gets out of balance with nature that pande­mics become more likely. Instead, as with climate change, we are fiddling while our world burns.

The conver­sa­tion was conducted in writing.
Mark Honig­sbaum, The Pandemic Century. A history of global conta­gion from the Spanish flu to Covid-19 (Cambridge, MA: Penguin 2020; first edition: The Pandemic Century: One Hundred Years of Panic, Hysteria, and Hubris (London, New York: Hurst; Norton 2019)