The century of pande­mics. A conver­sa­tion with Mark Honigsbaum

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 18^th 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”.

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 21^st 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)