by Sonia Shah
All of which is to say that our vaunted sense of individuality is an illusion. Animals like us, as the evolutionary biologist Nicole King has said, have never been single organisms. For better or worse, we’re “host-microbe ecosystems.” Microbes shape us from without and also from within.43
That is to say, pathogens and pandemics are not solely the products of modern life. They’re part of our biological heritage. The predicament we find ourselves in today, on the threshold of a new pandemic, is hardly exceptional. It’s of a piece with hundreds of millions of years of evolution.
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In many ways, we remain as diminished by pathogens today as we were eons ago. Globally, we’ve conquered barely more than a handful. New pathogens encroach upon us by the hundreds, threatening a pandemic. Meanwhile, old ones continue to exact their pounds of flesh: nearly half of all deaths in people under the age of forty-five are due to infectious disease.44
And yet at the same time, our prospects have never been better.
Consider the fact that of the three existential challenges faced by all species, pathogens are just one. Our conquest over the other two—predators and Earth’s often hostile climate—has been nearly complete. We’ve been incrementally transforming hostile climes to suit our needs and comforts since our ancestors tamed fire one million years ago, banishing the night and the cold the way our central heating systems and hermetically sealed glass windows do today.45 Our battle with predators was settled when we walked out of Africa one hundred thousand years ago and into the world’s continents, rapidly driving every other large mammal—and the predators that hunted them—into extinction. We rid our habitats of the American lions, the mastodon, the mammoths, the saber-toothed cats, and the other hominids such as Neanderthals that might have preyed upon us. Our sole predators left now are other humans.46
I don’t mean to argue that the way we subdued the environment and other species was without negative ramifications. But it shows the extent of human capacities when we can apply our intelligence and tool-making skills to the task. Because both of these existential challenges have been obvious to us for thousands of years—even our earliest ancestors could recognize the destructive power of storms and the danger that predators posed to them—we’ve been able to wield our own agency to overcome them.
In contrast, for most of our history, we’ve been unaware of pathogens’ role in our lives. We developed the technology to detect microbes less than two centuries ago. We are just beginning to grasp the extent of their secret world today. It may have seemed, with the development of antibiotics and other wonder drugs in the mid-twentieth century, that we’d conquered our old foes. But seen in a larger historical context, we look more like climbers on top of a foothill, mistakenly thinking we’ve reached the summit. The project of applying our intelligence and tool-making skills to the challenge pathogens pose has only just begun.
TEN
TRACKING THE NEXT CONTAGION
“Well, you’ve scared the shit out of me,” the bearded man sitting in the front row said to me when the question-and-answer session began.
It was the spring of 2015 and I’d just finished an hour-long presentation about pandemics to a crowd of students and faculty at a small boarding school outside Minneapolis. It wasn’t the first time I’d heard a version of that response. I’d been talking about the science, politics, and history of pandemics to physicians’ groups, students, and academics for a year or so. And afterward, as audience members filed out of the auditoriums and conference rooms, I had overheard more than a few laughing nervously and whispering to each other about needing to go wash their hands.
Remember the hysteria around SARS? the bearded man asked. Avian flu? Ebola? We’d panicked every time, but then when the outbreaks subsided, we went back to ignoring contagions altogether, he said. What’s the point? Would we ever be able to terrorize ourselves into containing the next contagion?
From his perspective, I had just spent the previous hour under stage lights frightening my audience, so my response probably seemed contradictory. I agreed with him. Outbursts of fear are indeed futile. But that’s not because fear itself is a problematic response to the challenge that pathogens present to us, which is formidable. It’s because of where that fear comes from.
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One of the most spectacular demonstrations of fear about pathogens in recent history occurred during the 2014 Ebola epidemic in West Africa. While scores of impoverished slum dwellers in Monrovia and Freetown perished, people from the suburbs of Kentucky to the air-conditioned offices of Canberra were gripped by the terrifying notion that Ebola would come to get them, too.
According to polls, nearly two-thirds of Americans feared an Ebola epidemic in the United States.1 Terror-struck, they avoided contact with anyone who’d visited any locale on the same landmass as the affected countries, no matter how distant. From Connecticut to Mississippi, schools closed their doors to teachers and students who’d visited countries that were thousands of miles away from the outbreak—Kenya, South Africa, Zambia, Rwanda, and Nigeria—forcing them into three-week-long quarantines (the amount of time it would take for a latent Ebola infection to manifest itself in symptoms).2 A school board in Maine went so far as to compel a teacher to quarantine herself after she attended a conference in Dallas because it was held ten miles away from a hospital where a man who’d been infected with Ebola in Liberia had been treated.
Any sign of unusual illness in travelers or people perceived to be foreign and thus possibly infected with Ebola similarly elicited elaborate containment and avoidance measures. A frightened flight crew locked a passenger who vomited midflight between Dallas and Chicago in the plane’s bathroom, for fear the passenger was suffering from Ebola.3 A woman who vomited after getting off a shuttle bus at the Pentagon was met by a hazmat team, who isolated her and quarantined the military officers on their way to a Marine Corps ceremony. By November 2014, the Centers for Disease Control felt compelled to assuage consumers with a special note about their upcoming feasts, assuring them that they wouldn’t get Ebola from their Thanksgiving turkeys.4 U.S. politicians inflamed the panic, with one going so far as to warn the CDC that “illegal migrants” from Mexico were carrying Ebola (along with swine flu, dengue, and tuberculosis) over the border into the United States.5
The hysteria was not restricted to the United States. In November 2014, the government of Morocco canceled its plans to host the 2015 Africa Cup of Nations soccer match, despite the fact that none of the affected countries had qualified to participate and few visiting fans were expected. American and European travel agencies stopped offering tours anywhere on the continent of Africa.6 Mexico and Belize refused to allow a cruise ship to dock on their shores because it was carrying a passenger who had handled lab specimens from an Ebola patient in Dallas. The fact that the passenger had not been exposed, was not ill, and had already been quarantined on board did not shake their resolve.7 In Prague, a student from Ghana shivering on a train platform was carted away by fifteen police officers and an emergency responder wearing a full hazmat suit. It turned out he had a cold. At an airport in Madrid, a crowd of passengers stood aside and watched, frozen in horror, as a Nigerian man collapsed onto the floor and lay there shaking for nearly an hour. He was suffering from a cocaine overdose.8
The panicked reactions were so pervasive that they impeded the international effort to control the outbreak in West Africa. While the governments of Guinea, Liberia, and Sierra Leone pled for international help, airlines canceled flights to the affected countries, leaving aid workers stranded. In Australia and Canada, travel to and from West Africa was summarily banned, while elsewhere, draconian quarantine restrictions were put into place for those who visited the affected countries.9 Hospitals, government agencies, and private citizens stocked up on so many biohazard suits to protect themselves from the hypothetical outbreak that there weren’t sufficient stocks left for aid workers en route to fight the actual epidemic in West Africa.10
When the bearded man questioned the utility of our fearful reactions to pathogens, he undoubtedly had this seemingly irrational public reaction in mind. What was the point of the spectacle? After all, the risk that Ebola actually posed to the industrialized world was exceedingly low, public-health experts agreed. There were precious few transmission opportunities for a pathogen like Ebola. The virus could spread only if people ingested the bodily fluids of victims in the throes of infection, which was unlikely to happen with any regularity in places where the sick seek treatment in modern hospitals and the handling of corpses is left to professionals. So why were the parents of schoolchildren in Maine and flight crews in Dallas so afraid?
Most commentators chalked it up to ignorance and paranoia. A mocking term to describe the phenomenon, “Ebolanoia,” gained popularity on social media. PolitiFact called Americans’ fearful exaggerations about Ebola the “Lie of the Year.” The Economist called it an “Ignorance Epidemic.” More Americans had been married to the reality television celebrity Kim Kardashian, commentators pointed out, than had died of Ebola.11
But dismissing Ebolanoia as an expression of ignorance missed its larger meaning. Far from being pointless idiocy, the fears that Ebola provoked in the industrialized world revealed something important about prevailing attitudes about pathogens, and how the next pandemic might be received. Fear is a response to the unexpected. Somehow, something about Ebola had violated modern expectations about pathogens and their role in our lives.
Consider how the same societies that panicked about Ebola responded to other new pathogens. Take Lyme disease, which has steadily marched across the country since first emerging in 1975, and which is now diagnosed in three hundred thousand Americans every year. Diagnosis and treatment are tricky. While a prompt course of antibiotics can nip the disease in the bud, because of the difficulty in diagnosing the infection (one out of five people infected with the bacteria doesn’t develop the telltale bull’s-eye rash that distinguishes the disease, and blood tests are vague and undiscerning), many cases go untreated. Victims then suffer a wide range of long-lasting symptoms, as the infection spreads to the joints, the nervous system, and the heart. Children are especially vulnerable, with boys between the ages of five and nineteen suffering three times more Lyme than adults. And their lives are profoundly disrupted by the pathogen. Children with Lyme suffer symptoms for nearly a year, a CDC study found, and miss more than one hundred days of school on average. A 2011 study found that over 40 percent of children with Lyme suffer suicidal thoughts and 11 percent had made a “suicidal gesture.”12
And yet, in the epicenter of the epidemic, the disease evokes little more than a collective yawn. New York State accounts for nearly a third of the nation’s cases, and Ulster County, home to the leafy campus of the State University of New York in New Paltz, is the eighth-most Lyme-infested county in the nation. I taught a journalism class there during the spring of 2013. Nearly all of the students in the class had been touched by the disease in one way or another. One student’s mother had been infected years before and was “never the same” afterward, the student said, plagued by strange, lingering, and mostly untreatable symptoms. Another remembered Christmas gatherings during which young cousins would stumble around, suddenly paralyzed by Lyme. Still another was a survivor of the disease herself. And yet none expressed fear about their own chances of getting infected or professed to taking even the most rudimentary precautions to avoid the bites of ticks. (The CDC recommends applying repellents and wearing insecticide-treated clothing, among other things.) There was zero demand for tick-repellent outdoor clothing at the local outdoor-gear shop. There were no signs about infected ticks along the popular twenty-four-mile hiking trail behind the campus that students and visitors frequented, although ticks would attack by the dozen if one veered even a few feet into the brush. And although nearly all of my students planned to become professional journalists, few saw the Lyme disease epidemic as a newsworthy story.13
The emergence of dengue in Florida in 2009 was met with similar indifference. The mosquitoborne disease is known as “breakbone fever” in Asia and Latin America for the intense muscle and joint pain it causes. Most of those who fall ill recover and many who are infected don’t fall ill at all. But repeated infections can be deadly. They increase the risk that victims will suffer a more severe form of the disease, including a life-threatening complication called dengue hemorrhagic fever.14
Still, the people of Key West scoffed at news of dengue’s arrival. Making conclusions about the presence of dengue in a 250,000-strong population on the basis of a sample of a few hundred people—a standard practice that is widely understood to be statistically valid—made no sense, they said. “It’s inaccurate,” one local said. “If that’s the way science works, that just seems really weird to me.”15 The idea that several dozen people suddenly falling ill from a novel virus constituted an “epidemic”—the standard term for such an event—was “very alarmist,” another said. “The idea that there’s an epidemic here, or that we’re on the verge of an epidemic, is just false,” a county tourist official added.16 In a scene reminiscent of the cholera balls of 1832 Paris, a group calling itself Dengue Night Fever pranced through the streets of Key West in the summer of 2010 wearing giant mosquito wings as the virus swirled around them unseen. Undoubtedly, some of the people in Key West pooh-poohing dengue relied in some way on the tourism industry that dengue would threaten. But tourists themselves, The New York Times reported, “seemed oblivious” of the ongoing outbreak. One man, with a fresh mosquito bite on his arm, said, “We haven’t heard anything about it. We are having a wonderful time.”17 Another visitor had never heard of dengue either, despite being a nursing student and a Florida resident of forty years. “I typically don’t wear mosquito repellent,” she admitted. “I don’t think about it.” (Her dengue infection landed her in the emergency room. “It was the worst ten days of my life,” she said.)18
Of course, every pathogen is different, and its reception is shaped by its specific qualities along with the historical context in which it debuts. Most people in North America and Europe knew, however dimly, that Ebola originated in a distant, exotic place (that is, in a village near the Ebola River, in the Democratic Republic of Congo). That alone may have made it seem inherently more dangerous to Westerners, compared to something named after a leafy Connecticut suburb, like Lyme disease, simply because its birthplace is less familiar. It’s also highly virulent. Ebola kills about half its victims, on average. In contrast, Lyme is rarely deadly and dengue hemorrhagic fever kills about 10 percent of its victims.
But none of these specific differences explains why Ebola terrified and other new pathogens did not. The exotic origins of, say, West Nile virus and dengue are obvious, too, and yet neither inspired Ebola-like panic. And if virulence were the main determinant of the fear response, the most terrifying disease would have to be rabies, which kills every one of its victims in a matter of days. But culturally speaking it’s more punch line than nightmare. On an episode of the critically acclaimed comedy The Office, for example, the show’s most absurdly out-of-touch character organizes a “fun run” for rabies awareness (titled “Michael Scott’s Dunder Mifflin Scranton Meredith Palmer Memorial Celebrity Rabies Awareness Pro-Am Fun Run Race for the Cure”). The other characters are indifferent, participating by taking taxis and drinking beer and shopping along the way. The joke is that the race organizer ludicrously thinks rabies is a terrifying disease, but the reasonable characters know that it is not.
Ironically, while the seemingly disproportionate alarm triggered by Ebola was roundly condemned, the more dangerous response to new pathogens is probably indifference. One example is the case of our oldest and most resilient pathogen, the one that causes malaria. We’ve had malaria since we evolved from the apes, and to this day it takes hundreds of thousands of lives every year. And yet it’s fully preventable and curable, and has been for centuries. Medical anthropologists have repeatedly found that the re
ason we still have so much malaria is that many people in malarious societies take few precautions to protect themselves from the disease. They don’t sleep under mosquito nets. They don’t get diagnosed or treated when they fall ill. Why? Because they think of malaria as a normal problem of life. Malaria persists because it has ceased to inspire fear.
Malaria is an endemic disease in most places where it occurs. Endemic diseases are arguably much worse than epidemic ones. They are harder to get rid of, for the reasons noted above, and more burdensome, too, because they regularly sicken and kill year after year and not just in a single outburst. Cholera has already made the transition from epidemic to endemic status in Haiti. As an endemic disease, it will be a continuous drain on Haitian society for the foreseeable future and a permanent threat to the region. Cases have already appeared in Florida, the Dominican Republic, Cuba, Puerto Rico, Mexico, and the Bahamas.19
Dengue is expected to become endemic in Florida, has emerged in Texas, and will likely spread farther north, too, touching millions. Lyme disease is steadily spreading across the United States and drains the economy of hundreds of millions of dollars a year. But once they stop provoking fear, pathogens have secured the golden ticket. They no longer have to mount our defenses because there’s little public interest in putting up defenses. The complacency of Floridians and New Yorkers to the new pathogens in their midst is the first step in the cultural and biological process by which itinerant epidemics turn into deeply rooted endemic diseases.
