Epidemics, Outbreaks and Pandemics
The Pandemic Century

Epidemics, Outbreaks and Pandemics

Prolific medical historian Mark Honigsbaum provides a chilling, detailed overview of the human experience of pandemics.

The coronavirus that caused SARS was a harbinger of what’s to come. 

In early 2003, Mark Honigsbaum reports, a Chinese bat likely infected a civet in one of China’s “wet markets,” where multiple species of live animals sit side-by-side in cages waiting for someone to buy, butcher and eat them. The bat may have carried the virus – severe acute respiratory syndrome coronavirus, SARS-CoV – that caused severe acute respiratory syndrome (SARS). Scientists had believed that coronaviruses attacked only animals, and were mild when they crossed over to humans. The virus itself was thought to lack a protein that would allow it to bond with a human cell. Nevertheless, either directly from the bat or from an infected mammal, Honigsbaum tells, the virus gained its missing protein.

The virus infected a Chinese businessman who traveled to Hong Kong and checked into the Metropole Hotel in February 2003. He contaminated surfaces and the air for hours. Honigsbaum stresses that people who were only in elevators picked up the infection. They traveled throughout Hong Kong and elsewhere.

Before the containment of SARS, the virus, Honigsbaum cites, infected 8,422 people in 30 countries, killing almost 1,ooo. Scientists quickly isolated the virus, then developed and distributed test kits. The SARS epidemic began in an open city with first-rate laboratories and specialists – Hong Kong. Harsh measures isolated the infected. Success in containing SARS provided a false and dangerous sense of security. “One of the major dangers arising from the effective control of SARS,” the author writes, “is complacency.” 

“Spanish flu” was history’s greatest pandemic.

When the United States entered World War I, Honigsbaum explains how it built enormous camps to house and train the expeditionary force that would join the Allies in the trenches of Europe. The Army housed tens of thousands of soldiers – some from farms and others from cities, recent immigrants and American-born. Their intermingling in close quarters led to epidemics of bacterial diseases, including measles and pneumonia. It gave rise to the first wave of the worst pandemic in human history – the 1918 Spanish flu. Honigsbaum describes how patients developed severe headaches and coughed bloody phlegm. Gradually, they struggled to breathe, and turned blue before dying.

More than 650,000 Americans – troops and civilians – succumbed, as did up to 100 million people worldwide. Only Australia, Honigsbaum notes, quarantined itself and suffered no deaths. In Philadelphia, authorities’ failure to enforce social distance and cancel public events caused more suffering than in any other American city. 

A successful virus, Honigsbaum emphasizes, does not want to kill its host. It wants to spread. The Spanish flu taught scientists that overcrowded and unsanitary conditions are predictable conditions for an outbreak. It revealed the complex nature of viruses and bacterial disease – including showing a strain might affect people differently depending on their age, race, socioeconomic background, and the like.

Plague constantly lurks. 

From the 6th to the 8th centuries and in the 14th centuries, Honigsbaum relates how plague killed more than 50 million people in the Eastern Roman Empire – one-third to half of the population. He offers the surprising fact that plague still exists worldwide, in fleas that live on rodents. Honigsbaum provides, as an example, that from about 1900 to 1925 plague killed many dozens of people in San Francisco, Oakland and Los Angeles – almost every person who came into contact with it.

Honigsbaum laments that officials tried to suppress news of the outbreak. They threatened scientists who discovered it, fearing the economic impact news of plague might cause. Quick and drastic action to quarantine overcrowded and unsanitary areas, plus massive extermination efforts aimed at rats and squirrels, largely contained these outbreaks. “Faced with the publicity nightmare of a disease from the Dark Ages appearing in 20th-century Los Angeles,“ the author writes, “it is little wonder that the first instinct of the city’s civic leaders and their press allies was to obfuscate.”

Today, physicians use antibiotics to treat the handful of Americans who contract plague each year. Though plague kills 16% of its victims – even with treatment – Honigsbaum characterizes it as a minor threat because governments appreciate its virulence.

Parrot fever was an airborne pathogen from the jungles of South America. 

No sooner had the plague epidemic ended, Honigsbaum makes clear, than a pandemic began in 1930 with the Kalmey family in Maryland. The symptoms looked like typhoid or pneumonia. Luckily, the family doctor mentioned the Kalmeys’ dead parrot to his wife, who had read an obscure article about a so-called parrot fever in Argentina. American officials put the word out, and cases emerged from various states. The press alerted the public and generated demand for action.

The disease spread across the United States and parts of Europe and Africa. Initial theories held that it likely came from imported exotic birds. Many birds in the wild die in epidemics, but most survive and carry the parasite. As researchers discovered, the disease transmits through the air in dried droppings, making it highly contagious. It spread even though the government imposed a ban on imported birds in January 1930.

Epidemiologists went to Washington’s Public Health Service laboratory, the “Hygienic” – later to become the National Institutes of Health – to study the disease. It swept through the laboratory, infecting a dozen researchers and workers. An experimental serum saved all but one person. As the disease spread, killing 15% of its victims, demand for a scalable serum mounted. Scientists, Honigsbaum learned, discovered that the main culprit was not imported parrots, but California-bred parakeets and songbirds. This business supported thousands of workers. The industry lobbied hard, delaying a ban against interstate trade. 

The disease continued to spread. Fortunately, a highly effective serum saved those who had the infection. Since then, responsible breeders have used antibiotics in bird feed to prevent another out break. Scientists again saw how bacterial and viral parasites in animals may stay in equilibrium for centuries, but when people upset the ecology, epidemics or pandemics emerge. “Most cases of disease emergence can be traced to the disturbance of ecological equilibriums or alterations to the environments,” the author writes, “in which pathogens habitually reside.”

Legionnaires’ disease provided a national wake-up call. 

In July 1976, Honigsbaum recounts, thousands of war veterans gathered in Philadelphia for an annual American Legion jamboree. Hundreds stayed at the Bellevue-Stratford hotel, the convention site. A week after the event, legionnaires fell ill throughout Pennsylvania. By August, the epidemic had swelled to 100 victims, with 19 deaths. This drew the attention of the media, the public and the Centers for Disease Control (CDC). Researchers interviewed everyone, mapped legionnaires’ movements outside and inside the hotel, studied the patients and the victims, and tested the hotel’s food, water and, eventually, the air conditioning systems. Honigsbaum discusses how hotel staff remained unaffected, even though a number of people who had only walked past the hotel contracted the malady. It eventually earned the nickname Legionnaires’ disease.

As the CDC came up with clues that led nowhere, the press and others began to speculate. Honigsbaum conveys how they floated theories of pigeon-borne viruses, terrorists, gas attacks, plague, cover-ups and conspiracies. Some members of the CDC team suspected the hotel’s rooftop water coolers, which were in proximity to the drinking water supply. The team saw rod-shaped bacteria in cell samples from infected people, but dismissed them as anomalies. They searched for a virus. For years, what happened in Philadelphia was “the greatest epidemiological puzzle of the century.”

Honigsbaum evokes how the bacteria bothered Dr. Joe McDade. New to the field and not easily put off the trail, McDade performed experiments. He compared the bacteria to those found in victims of similar outbreaks in Michigan and elsewhere. That bacteria – Legionella pneumophila – linked the outbreaks. The cooling towers at the hotel were the breeding ground. 

Legionnaire’s disease, Honigsbaum concludes, demonstrated that new epidemics can come out of nowhere. New environments – in this case, created by air conditioning and other technologies – produced a niche that an ancient, previously harmless disease could exploit. Add the right mix of guests (elderly people socializing), the right weather (a heat wave) and a means for the bacteria to spread (probably through vents or even shower drains), and a new, mysterious pathogen could thrive. Today, Legionnaires’ disease accounts for about 2% of US pneumonia cases. Doctors can use specific antibiotics to treat it, yet Honigsbaum finds it maintains a mortality rate of 9%.

Complacency and inaction regarding AIDS led to 50 million deaths – so far.

Honigsbaum makes the case that the second-deadliest pandemic of the 20th century – AIDS – began in the 1970s, but scientists did not identify it until 1980. Young, otherwise healthy men began showing up in hospitals with a rare form of pneumonia, dying in droves. Physicians and scientists took notice. To date, the HIV retrovirus has killed more than 50 million people worldwide.

When AIDS first appeared, Honigsbaum expresses outrage that politicians ignored it – many believe, because it affected drug addicts and people with so-called “deviant” sexual lifestyles. The author believes that only when film star Rock Hudson went to France for treatment did the government release funds for AIDS research, and the average person start paying attention. Ambiguous public health messaging led to a nationwide scare. People thought they could contract AIDS from a handshake and that HIV could live for hours on surfaces, including toilet seats.

Honigsbaum breaks down how AIDS incubates, often without symptoms, for about 10 years or more while its carriers infect others. It likely developed in Central Africa as far back as the 1920s. It spread to the general population – men, women and children – in almost equal measure. The advanced medical equipment and techniques of the 1980s allowed researchers to distinguish AIDS from an unknown pneumonia that had killed its victims for decades. “If Legionnaires’ disease had been a warning to an overly complacent public health profession,” the author writes, “then AIDS was the epidemic that drove home the lesson.” 

The invasion of previously inaccessible places, possibly in the Congo interior – combining with the practice of eating bush meat and the use of new road, rail and, then, air routes – allowed AIDS to escape and create a global pandemic. Today, Honigsbaum reveals, people can live with AIDS, but uncomfortably, with the support of a powerful daily drug cocktail. 

The horrific killer Ebola escaped Africa. 

Honigsbaum cautions that Ebola’s mortality rate of up to 90%, and the way it sometimes kills – with blood streaming from a victim’s every orifice – evoke horror. Initially, experts thought that Ebola was isolated in rural East Africa and was insufficiently virulent to spread to African cities, let alone anywhere else in the world.

But in December 2014, a two-year-old boy – part of a group of kids who had been catching and eating fruit bats – fell ill with Ebola in rural Guinea, sparking the worst outbreak of the disease in history. The virus traveled with its human hosts along roads to African cities, and then onto planes elsewhere. Honigsbaum blames poor communications for creating deadly animosity between African villagers and the medical teams that came in to fight the virus. A lack of medical infrastructure, virtually no infectious disease labs, a slow response by the World Health Organization (WHO) and local leaders’ denial of the facts rapidly escalated the contagion, as did West African burial rites calling for mourners to have close contact with the deceased.

Honigsbaum refers to WHO’s declaration of a “pheic” – a “public health emergency of international concern.” This mobilized a global effort, including the use of international troops, that contained the epidemic. In the end, 29,000 people suffered infection, and 11,000 died.

It’s not a question of if the next pandemic occurs, but when.

The past century or so brought frequent, unprecedented epidemics and pandemics, including Zika in 2015. Events proved experts and conventional wisdom wrong each time. Scientists have discovered hundreds of infectious diseases since 1940, and will find many more. Some will cause new epidemics and pandemics. New plagues will emerge. “Reviewing the last 100 years of epidemic outbreaks,” the author writes, “the only thing that is certain is that there will be new plagues and new pandemics. It is not a question of if, we are told, but when.”

Honigsbaum celebrates the heroes of this story – health care workers, medical researchers and scientists – who stand between humanity and pandemic catastrophe.

Horrifying, Illuminating Tales

Medical historian and pandemic commentator Mark Honigsbaum could hardly have better timing. His profoundly-researched, in-depth informed reportage arrives at exactly the moment when everyone wants to know more about the history and processes of pandemics. Honigsbaum shows his deep knowledgeable but doesn’t attempt to impress laypeople with medical arcana. He remembers the human element in every one of these tragedies. He writes repeatedly of how people make the same mistakes over and over, and how those mistakes foment these terrible diseases. The foremost mistake, he finds, is ignorance. Honigsbaum’s mission is to keep readers from succumbing to the errors of ignorance, and he succeeds in this gripping, fascinating and frightening read.

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