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”.
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)