The Long Bust – Point 9: An uncontrollable plague – a modern day influenza epidemic or its equivalent – takes off like wildfire, killing upward of 200 million people.
It Doesn’t Take 200 Million Dead to Bring Global Civilization to a Screeching Halt” by Broomstick
My main criticism of “The Long Boom” is that the predictions depend on everything working out, everything going to plan, no major problems along the road into the future. The author acknowledged this with the “Ten Scenario Spoilers” and I’m here to discuss #9.
The text of that spoiler reads: An uncontrollable plague – a modern-day influenza epidemic or its equivalent – take off like widlfire, killing upward of 200 million people. Pretty much everyone in today’s world will immediately think “oh, covid-19”. Which, yes, qualifies as a pandemic and a scenario spoiler, even if arguably it was a pandemic on “easy-mode” that (at the time of this writing) has killed “only” 6 million people.
There are three errors in the original article. They are are follows:
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Estimates of fatalities and medical consequences seem to have been made on the basis of prior historical pandemics, almost all of which occurred prior to antibiotics and what we consider modern medicine. Modern pandemics may be extremely disruptive without death rates as bad as past pandemics.
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Failure to take into account that public-health experts have looked at past pandemics, studied them, and taken steps to prepare for the next “big one”. Again, having plans in place can (but do not always) mitigate the effects of widespread disease.
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Failure to consider the economic, social, and other fall-out of this scenario. Admittedly, the main article didn’t address negatives much in its relentless optimism, but as we have recently scene a pandemic doesn’t have to have a high fatality rate to have a high impact on the world.
The last big global pandemic in the mind of most people is the Influenza Pandemic of 1918-1920 which was truly global in extent and killed 25-50 million people (estimates actually range from 17 to 100 million, but the 25-50 million is a more commonly accepted range). It should be noted that at the time there were no antibiotics and no mechanical ventilation for people with breathing difficulties, two factors that drove up the death rates for any disease that could compromise the lungs. A number of medications that can provide supportive treatment for severe disease also did not exist yet. Cytokine storms, which were possibly one cause of the death toll among relatively young and healthy people during the 1918-1920 pandemic, were not recognized or understood back then but today we not only are aware of the condition and the risk factors for it but also have treatments. While cytokine storms do kill people today they are no longer the death sentence they used to be. All of this means a pandemic occurring any time after the mid-20th Century would be different than one occurring earlier. It is no accident that smallpox, a source of recurring epidemics world-wide, was eliminated in the second half of the 20th Century rather than at an earlier time.
Another new factor in pandemics is modern transportation. Some of this was seen as early as 1918, with the advent of global travel by trains and ships as well as massive movements of people stemming from World War I which contributed greatly to that pandemic. The situation is even more problematic today with air travel routine and low enough in price that even the world’s poor can be found traveling from place to place by air. Someone infected in the morning can be half a world away on another continent by evening.
The combination of what would, today, be considered inadequate medical sciences and rapid travel worked together to ensure that the Influenza Pandemic of 1918 was second in death toll only to Afro-Eurasian Black Death of 1346-1353.
This resulted in the Influenza of 1918 influencing predictions about the next “big pandemic”, including prospective death tolls. There is a saying that military planning for the future reflects the most recent war in the past and this can also be said of planning for the next pandemic. While there is much to learn from 1918-1920 it is important to consider advancements in relevant areas such as medicine.
In reality, there have been other pandemics between 1918 and 1920. The 1957-1958 flu pandemic is one that is largely forgotten (although not entirely) but killed somewhere between 1 and 4 million people world-wide ( a smaller death toll that the current covid pandemic). A major difference between 1918 and 1957 was improved medical care – the world had antibiotics for secondary infections, including bacterial pneumonia, for example. This helped to keep death rates down. In addition, the rapid development of a flu vaccine for that strain of the virus also helped. These two factors – medical treatment for the ill and ability to develop vaccines – would drive down fatality rates for future disease outbreaks of all sorts.
Another flu epidemic occurred from 1968-1969, the Hong Kong flu, caused by a descendant of the virus that caused the 1957-1958 pandemic, and again killed between 1 and 4 million people world-wide. Again, medical support and the development of a vaccine (and likely some lingering immunity the 1957 outbreak) reduced the potential severity of the disease.
This set two patterns going forward: the assumption that the next Big Pandemic would be a type of influenza virus (antibiotics made bacteria-based pandemics highly unlikely) and, despite some economic and social disruption, a notion among governments and the general population that these disease outbreaks wouldn’t be that bad – serious, but not something world-changing.
Public health authorities were not so sanguine. There were several incidents/outbreaks that could be described as “scares”, where public health authorities raised an alarm but none of them (even the one with a death toll in the tens of millions) became the Next Big Pandemic. In retrospect, this is because the interplay of both modern medicine and public health knowledge blocked the spread of these diseases before they could turn into epidemics.
HIV/AIDS dates back to 1981 and is still on-going, with an estimated death total of 36 million but that death total has been distributed over 40 years, or an average of less than 1 million people per year which is a different circumstance than the flu pandemics that killed multiple millions in less than a year. While certainly frightening at the beginning, a time when contracting the virus was a death sentence and someone could spread the virus for an extended period of time before showing symptoms leading to global spread, transmission was through the route of body fluids and the average person could vastly reduce his or her risk by simply not having risky types of sexual contact, not sharing needles for IV drug use, and avoiding blood transfusions. Even without modern medicine a person could take steps on their own to avoid infection.
A few years into the HIV outbreak new testing for the blood supply made that route of transmission nearly (although not entirely) disappear. During the 1980’s we saw the use of personal protective equipment (gloves, face shields, gowns, etc.) in many settings become routine that not only reduced the possibility of HIV transmission but the transmission of other diseases as well. We now take it for granted that when we visit a dentist office or a tattoo shop gloves, masks, sterilization, and sanitation are routine, in some cases proudly promoted as an example of care for patients and customers. This normalization of protective techniques makes it harder for the next pathogen to achieve epidemic or pandemic status.
In the industrialized world HIV became a disease affecting marginalized minorities (homosexual men and IV drug users) and thus faded from the concern of many, even if in some places, such as sub-Saharan Africa, it became established among the heterosexual population and caused much more damage (which also illustrates how cultural and economic factors can affect disease spread). In time, new medications changed HIV infection from a death sentence to a serious but manageable chronic condition (provided you had long-term access to drugs and the side effects weren’t intolerable for an individual). Due to the characteristics of this disease, although it was viral in origin and nearly 100% lethal in the early days, it never generated the fear and disruption caused by other widespread diseases. A disease has to spread rapidly among a large general population in order to cause a pandemic. Once the world understood how HIV was transmitted there were fewer new infections, even among the most vulnerable groups, even before there were effective treatments. HIV was not the next Big Pandemic although it remains a serious disease that continues to infect and kill people.
Ebola is another scary disease that has been waved as the next Big Pandemic for years and generated some discussion during and after the 2014 outbreak. It certainly is scary, causing a gruesome death, but it’s not suited to being a Big Pandemic disease for a couple reasons even as it remains a serious disease with nasty outbreaks in Africa. [url=https://boards.straightdope.com/t/basic-facts-on-ebola-we-need-to-know/701599]First of all, it is not airborne. It is spread by contact with blood and other bodily fluids.[/url This is problematic in its area of origin where relatives typically prepare the dead for burial and seldom have the training or personal protective equipment to prevent ebola transmission, but in other parts of the world where tending to the bodies of the dead is more formalized and protective equipment readily available for both medical personnel and those taking care of the dead transmission is much less likely. It can still happen, but it’s not a run-away spread of infection necessary to sustain an epidemic. The other reason ebola is less likely to be a Big Pandemic is how quickly it disables the infected at the point where they can spread the disease – those who fall ill become very sick very rapidly, very obviously severely ill (which hastens them being put into isolation), and too ill to move around much or travel, thereby also limiting spread.
In order to generate a Big Pandemic a disease must be easily transmitted and there must also be period of time in which the contagious can spread the disease before being disabled or dying. Also, it has to cause significant impairment during infection – a disease that transmits easily but causes few or no symptoms might be pandemic in spread but it’s not going to be disruptive enough to capture the public’s attention.
A second scare was the 2002-2004 SARS outbreak. That was more attention-grabbing than ebola for a couple reasons. For one, it appeared to airborne and containing airborne pathogens is more of a problem than blood-borne ones. However, the world dodged a bullet in that infected people are not very contagious in the initial few days of the illness. It is thus possible to identify people before they start spreading the disease and isolate them, leading to containment of the virus. This strategy was so effective, in fact, that the SARS virus seems to have disappeared – there have been no cases reported since 2004. It is possible that simple identification and isolation/quarantine was enough to drive this virus extinct. It was done so effectively that some doubted if it was really that big a deal and questions about it remained unanswered. So SARS was not the Big Pandemic.
Even so, public health authorities did learn from those two disease outbreaks, lessons that would help during the covid pandemic we are currently experiencing. Unfortunately, the succession of alarms over these diseases that might have been Big Pandemics but weren’t led to a Boy Who Cried Wolf effect, which I believe lead some authorities to discount early warnings over covid-19.
Covid-19 is the Big Pandemic we were warned about, but like most predictions of the future, it didn’t entirely match prediction. It was not a flu virus, for one thing, but a covid virus. In retrospect, this is probably not that surprising. For one thing, endemic flu can provide some partial immunity to new strains of flu, moderating the effect of outbreaks and global travel of flu viruses means instead of one population having experience with one flu virus and another population with a different one the global population shuffles multiple varieties at once, further increasing this partial immunity. Secondly, even in the 1950’s a vaccine for a new variant of flu could be produced in under a year, which would shorten the length of any flu outbreak (note that the 1918 outbreak lasted 3 years. The 1957 and 1968 outbreaks were just one year, development of a new vaccines shortening the length of the outbreaks). A covid virus would be another good candidate, especially after the 2002 SARS outbreak (which was also a covid virus), because it spreads via the air and there were no vaccines against covid viruses until 2021. Unlike the SARS virus – and this is a key factor in why covid became a pandemic and SARS did not - covid-19 is contagious before symptoms appear, which is really what allowed this to become the global pandemic it is. It shares this trait with HIV, which also has a long period of asymptomatic spread prior to the appearance of overt symptoms, but HIV requires close contact with bodily fluids. Such transmission is far easier to interrupt than anything airborne, especially once the mechanism is known.
In the end, the original article was far too optimistic in omitting pandemics from future predictions. There were four pandemics in the 20th Century: 1918 Flu, 1957 Flu, 1968 Hong Kong Flu, and 1981 HIV/AIDS. Of those four, three were flu, an airborne-spread virus. If it had not been for modern medicine the 1957 and 1968 flu pandemics may have rivaled the 1918 one. This is an important point: pandemics have actually been happening all along, but their effects have been muted by modern medicine. When predicting the future we should not talk about whether or not there will be future pandemics – there will be – but rather whether or not there will be a high impact, disruptive pandemic. The steps required to contain and mitigate covid disrupted global supply chains and economies around the world. Any prediction of the future extending more than a decade or two into the future needs to take into account that the global civilization will continue to experience both epidemics and actual global pandemics from time to time because pathogens continue to evolve. Sooner or later one evolves with the required combination of novelty (so as to evade immunity currently built up), transmissibility (so it can spread fast enough), and severity (to qualify as an actual illness) to generate a new pandemic. Medicine can mitigate the impact, but there is a cost to doing so, from the need to produce and distribute protective gear to the cost of treatments and medical staffing, to the effects of quarantines.
The results of pandemics are widespread. Labor shortages, shortages of goods, and economic disruption including both inflation and recession are common consequences, which we are seeing right now with covid-19. Also included are the mental effects of grief, isolation, fear, and stress with can manifest as increased violence (which we are also seeing), isolationism between nations, and possible negative effects on world leaders. These effects can derail globalization, disrupt trade, lead to hostility at all levels from individuals to entire nations, and exacerbate social problems, and negatively impact economies on levels from local to global.
So while we can’t predict when the next Global Pandemic will hit we know that it’s a matter of when, not if. We also now know that a pandemic does not require a high death toll in order to be massively disruptive on a global level. Predictions of the future should take this into account.