The Very Big Sick

Ask any expert in infectious diseases and they’ll tell you that when it comes to pandemics, it’s not a question of if we’ll have another one. It’s a question of when. Today’s episode investigates what the most likely killers might be, and whether we’re prepared or not.

Guests:

• Ed Yong, science writer at The Atlantic
• Nahid Bhadelia, assistant professor at Boston University School of Medicine and the Medical Director of Special Pathogens Unit (SPU) at Boston Medical Center
• Laura Spinney, science writer and author of Pale Rider: The Spanish Flu of 1918 and How It Changed the World
• Nicola Twilley, co-host of Gastropod and author of a forthcoming book on quarantine

Further Reading:

• The Next Plague is Coming. Is America Ready?
• Pale Rider: The Spanish Flu of 1918 and How It Changed the World
• Yuuyaraq: The Way of the Human Being by Harold Napoleon
• Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone
• Medicine’s Long, Thin Supply Chain
• What Bill Gates Fears Most
• Predicting virus emergence amid evolutionary noise
• Nebraska’s Biocontainment Unit
• The Terrifying Lessons of a Pandemic Simulation
• Clade X Livestream
• CDC Director: Why I Don’t Support A Travel Ban To Combat The Ebola Outbreak
• Protecting the Public’s Health from Diseases, Disasters and Bioterrorism
•  How prepared is the world for the next epidemic? This tool shows most countries are not.

Flash Forward is produced by me, Rose Eveleth. The intro music is by Asura and the outtro music is by Hussalonia. The voices from the future this episode were provided by Paul Krueger, Sean Raines, and Sameer Ajmani. The episode art is by Matt Lubchansky.

If you want to suggest a future we should take on, send us a note on Twitter, Facebook or by email at info@flashforwardpod.com. We love hearing your ideas! And if you think you’ve spotted one of the little references I’ve hidden in the episode, email us there too. If you’re right, I’ll send you something cool.

And if you want to support the show, there are a few ways you can do that too! Head to www.flashforwardpod.com/support for more about how to give. But if that’s not in the cards for you, you can head to iTunes and leave us a nice review or just tell your friends about us. Those things really do help.

That’s all for this future, come back next time and we’ll travel to a new one.

FULL TRANSCRIPT BELOW

▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹ ▹▹

Hello and welcome to Flash Forward! I’m Rose and I’m your host. Flash Forward is a show about the future. Every episode we take on a specific possible… or not so possible future scenario. We always start with a little field trip to the future, to check out what’s going on, and then we teleport back to today to talk to experts about how that world we just heard might really go down. Got it? Great!

This episode we’re starting in the year 2033.

Sound of sirens, chaos.

Nurse 1: I have another confirmed case here.

Nurse 2: Copy, location?

Nurse 1: Buckeye Road, corner of Lime & Buckeye.

Nurse 2: Condition

Nurse 1: Not good, stand by.

New Anchor: A recent outbreak of a mysterious disease has continued to spread from Florida out to nearby states. Doctors say that symptoms include aching joints, nausea, diarrhea, blurry vision, and headaches. Thus far, the virus has claimed three lives, and experts are unsure of where the disease came from. We’ll keep you updated as we learn more.

Nurse 2: I’ve got a case of the new thing, coming into the quarantine in five minutes.

Nurse 1: Copy, patient details?

Nurse 2: Male, 6’, blonde, rash on his upper shoulder.

Nurse 1: Copy we’re ready for them.

News Anchor: Quarantine facilities around the country are struggling to keep pace with the infection rate of S11, which has been spreading rapidly. Just yesterday, President Mandel officially declared a national of emergency, but spokespeople for these medical facilities say they’re not getting enough support. Without enough space or resources, they’re turning away infected individuals, how are contributing to the spread of S11.

Nurse 1: S11 coming your way

Nurse 2: Negative we have no beds.

Nurse 1: We don’t either, what do you want me to do.

Nurse 2: I don’t know but we have nowhere to put them.

Rose: Okay so this future is a scary one! A pandemic either emerges, and starts killing people, and scientists and policymakers have to figure out what to do and how to keep it from spreading.

Let’s start with the basic question: what is… a pandemic?

Ed Yong: That is a really good question. Okay, so we have phrases, like outbreaks and epidemics, to describe diseases flaring up in a sort of more contained way. So it’s not good, but it’s certainly contained geographically. We use the word pandemics when they really start to spread around the world.

Rose: This is Ed Yong, he’s a science writer at The Atlantic and he just wrote a really great, long piece about whether the United States is prepared for the next pandemic. And it turns out that the answer to that question is… complicated. In fact, nobody can even agree on what a pandemic is in the first place. The term is not a precise one. Some people think that the 2003 SARS outbreak was a pandemic. In case you don’t remember that one, in 2003 a Chinese food seller was hospitalized in Guangzhou, and they gave SARS to dozens of doctors and nurses. One of those medical professionals traveled to Hong Kong for a wedding and infected at least 16 people. Within six months, SARS was in 29 countries and had infected about 10,000 people, and killed about 1,000 of them.

So some people consider SARS a pandemic.

Ed: Others argue that it wasn’t, because there wasn’t a lot of spread within those countries that that subsequently got infected. It’s a bit like like art or porn; like you know it when you see it.

Rose: Often, when we think about pandemics, we think of really scary stuff, like Ebola. But Ebola is actually pretty unlikely to cause a truly global outbreak.

Ed: Ebola is not actually that easy to spread. It only spreads through bodily fluids, unlike

flu which spreads through the air.

Rose: In fact, the thing that is actually the most dangerous, the disease that really keeps pandemic experts up at night, is the flu.

Nahid Bedelia: For sure, I think anybody that you talk to says that the disease that is most likely to, sort of, lead to an overhaul and have a huge impact on both the population, economics is going to be some sort of novel influenza

My name is Nahid Bedelia. I’m an infectious diseases physician. I am the medical director of the Special Pathogens Unit at Boston Medical Center. It’s a unit that helps take care of patients with highly communicable infections.

Rose: The flu is one of those diseases that is always one step ahead of us. And that’s one of the many reasons that experts think that the flu is the most likely candidate to cause a global, catastrophic pandemic. And there have been flu scares in recent history. In 2009, for example, there was a moment where public health officials were really worried that we might be on the brink of a huge flu pandemic.

Ed: H5N1 bird flu was really the thing that everyone was most worried about. It was flaring up in China, it was killing off a lot of poultry and there were worries that it would spread around the world.

Rose: But while all the public health folks in the US were worried about bird flu coming from China, there was another strain of flu picking up steam just south of the border.

Ed: The CDC has a really good flu surveillance system. It’s excellent, it has really potent ways of keeping tabs on flus that are circulating in different corners of the world. But, you know, like every surveillance system, there are blind spots. And one of those blind spots happened to be in Mexico, where new strains of H1N1 flu were emerging among pigs. And those strains circulated beneath the threshold of everyone’s perception without the surveillance network picking it up. And it was only discovered when it started infecting a few kids in California.

Rose: Suddenly, it wasn’t bird flu that was making people in the US sick, it was swine flu. And the CDC and other public health folks were totally caught by surprise.

Ed: Everyone was sort of looking over here, and meanwhile a completely new strain of flu was coming up over there.

Rose: And this isn’t even some weird disease nobody has heard of before. Remember, it’s the flu.

Ed: This is one of the potential pandemic threats that we are arguably best setup to detect, and monitor. So being taken by surprise is, I think, a very important, cautionary moment.

Rose: A lot of public health folks call that 2009 scare a “near miss.”

Ed: One of the people I spoke to for this piece said that we dodged a bullet in 2009. But in fact nature just shot us with a BB gun

Nahid: People always say Well that wasn’t as serious as it could have been, you know. Maybe it was overreaction. The truth is it wasn’t as serious as it could have been, because partly, I think, there was a pretty good job in some major areas such as New York City, for example, of hospitals doing a great job of isolating patients, identifying them early, educating people to stay home if they’re sick.

Rose: But this actually gets at one of the big challenges when it comes to preparedness, and making sure you can keep funding preventative measures. If they work, they’re basically invisible.

Nahid: If its a disaster that didn’t happen, is hard for you to prove its value. Like, if you averted something, you can’t say, “well that could have happened,” because it didn’t. And so, that’s the tough part about preparedness. Proving that something is worth it when when it’s doing its job, basically there is a lack of events.

Rose: But further back in history there’s a big example of a pandemic that was not a BB gun, it was … I don’t even know… whatever the biggest gun you can think of is?

Laura Spinney: So the Spanish Flu of 1918 is a real anomaly. It killed between 50 and 100 million people. One in three people on earth was infected roughly, four to five percent of the whole human population was just wiped out.

Rose: This is Laura Spinney, a science journalist and novelist and the author of a book called Pale Rider: The Spanish Flu of 1918 and How It Changed the World, about, yes, the Spanish flu in 1918.

Nobody exactly knows where the Spanish flu came from.

Laura: The only thing we know with anything close to certainty is that it wasn’t Spanish.

Rose: The flu got the name Spanish flu because the pandemic hit during World War One, and news of the outbreaks were censored out of most of the newspapers in the warring countries. But Spain was neutral, which meant that Spanish newspapers were the first ones to report on the cases that broke there.

Laura: And it seemed to the rest of the world, and to Spanish people, as if it was the only country that had the disease to begin with. So the name was given and it stuck.

Rose: To this day, nobody actually knows who patient zero was for the 1918 flu pandemic. But there are three main theories. The first is that it came from Kansas.

Laura: So the first cases were officially recorded at a military camp, Camp Funston, in Kansas in March 1918. And those are officially the first cases of the pandemic by consensus. But we know that they can’t have been the actual first cases, because by then the flu was already highly contagious between people.

Rose: Usually the first cases of a flu like this aren’t actually that contagious, it takes a while for the virus to pick up steam.

Laura: Then the scientists begin to look for precursor events, precursor outbreaks, where perhaps it didn’t infect too many people. And there was such an outbreak in Haskell County, Kansas, in January of 1918, which killed a high proportion of those who caught it.

Rose: So that’s theory number one, Kansas. Theory number two is that it came from China.

Laura: An idea is that an outbreak of severe respiratory disease – and we know there was one, for example, in late 1917 in the Chinese interior – could have spread to the rest of the world.

Rose: For a long time, the problem with this theory was that nobody really knew how a virus that emerged in inland China wound up making its way all over the world. But in fact, more recent historical work has uncovered a potential pathway.

Laura: So, China was neutral in the war, but it was desperate to have a place at the eventual peace process that would happen, so that it can reclaim from the other powers territories it had lost over the preceding century. And it tried to find a way to contribute to the war, so as to gain that place that the the peace process without compromising its neutrality. And the ploy it came up with something called the Chinese Labour Corps. So it will provide a body of workers that would be recruited in China, and sent to Europe, to not take part in the conflict, but to work behind the lines. So assembling shells, repairing machinery, digging trenches and so on.

Rose: So it’s possible that the first cases of the Spanish flu came over in these workers, and then spread from there. But to prove that, scientists would have to have a sample of the virus involved in the precursor outbreak, that outbreak in China in 1917. And so far, they don’t have one of those samples. So they can’t compare that virus with the one that eventually became the Spanish flu.

Theory number three, is that the flu came from France.

Laura: there’s a virologist in Britain called John Oxford who has long been championing this theory. And he thinks that the conditions on the Western Front would have been highly conducive to creating a new respiratory disease of high virulence, which might then have easily be spread around the world by troops returning home. Particularly at the point when the armistice was signed, and demobilization started.

So there are three there is currently on the table – France, Kansas, China – and we cannot currently choose between them.

Rose: Regardless of where it came from, the Spanish flu arrived in 1918, and it swept across the world in three main waves.

Laura: One in the spring of 1918, one in the autumn of 1918, and then the third and final one in the early months in 1919.

Rose: Not all three waves were equally deadly, though. The first one was pretty mild, more like a seasonal flu. It was the second wave that was the really deadly one.

Laura: And this time it was much, much, much, more severe and had nothing in common with that spring wave.

Rose: The second wave of the Spanish flu was so different from the first that doctors at the time assumed that they were dealing with a completely different disease.

Laura: People mistook it for pneumonic plague, for cholera, and with typhus, which also comes on with flu like symptoms until you break out in a rash.

Rose: In Laura’s book, she has this totally chiling description of the way that the second wave of the Spanish flu would progress through people’s bodies. As people got sicker and sicker, they would often get these mahogany spots on their cheekbones, and those spots would then spread across their faces and eventually turn blue. And then, Laura writes, “Blue darkened to black. The black first appeared at the extremities — the hands and feet, including the nails — stole up the limbs and eventually infused the abdomen and torso. As long as you were conscious, therefore, you watched death enter at your fingertips and fill you up.”

In many cases, doctors and public health officials didn’t really know what they were even dealing with. 1918 was kind of an interesting, in between, time period when it comes to science.

Laura: It was a real mosaic in 1918, in the sense that some parts of the world had embraced germ theory – the idea that microbes cause disease which had been first been put forward around the middle of the 19th century – and some really had not.

Rose: The Spanish flu was technically an H1N1 flu virus. That’s a virus that is still circulating in the world today. But in 1918, the concept of viruses was really new. Not all doctors knew what they even were. And most of them thought that they were dealing with a bacterial disease, not a viral one.

The 1918 pandemic can teach us a lot of things about how a disease like this might spread. But it also shows us that the particular time period in which a disease emerges has as much impact on how it spreads as the biology of that disease.

Laura: A pandemic isn’t just a biological phenomenon, it’s a biological and a social phenomenon. So it’s very much shaped by the world into which it emerges, in terms of the human world, how humans are living at that time.

Rose: And in 1918, we can see that really clearly in a number of different places. Because not everybody responded to the pandemic the same way. Take New York City for example,

Laura: It was one of the most practiced cities in the world, in terms of public health. It had had a war on TB, for example, for 20 years. And so the population was used, in many ways to the authorities intervening in their lives. Telling them what to do in order to contain infectious diseases, which in many other parts of the world was a very new concept and something outrageous.

Rose: In New York, the health commissioner Royal S. Copeland was able to step in and do a few things that really quelled the spread of the disease.

Laura: The first was that he set up a system of emergency clearing centers across the city – one hundred fifty, if I remember correctly – which were to perform a kind of citywide triage on patients, and to count them as well. And that was very important, because you can’t manage a disaster of that scale unless you have constant and up to date information.

Rose: This might seem kind of obvious, and today we have these kinds of programs already up and running, but in 1918 this was a relatively new concept.

Laura: That was one excellent decision he took. Another one was to stagger rush hour, to stagger the opening and closing times of shops and factories, for example. So that you lessen the likelihood of large numbers of people accumulating in place of public spaces at certain times of day.

Rose: And the third big decision he made, and probably the most controversial, was to not close down the schools. Now, he didn’t come to this decision on his own. It was actually Josephine Baker, the head of the Child Health Department in New York, who encouraged him not to close down the schools, not to send all the kids home.

Laura: And she knew that many of the children in the city, particularly of the immigrant families, lived in terrible conditions. And it would be better if they were coming to school and the teachers could keep an eye on them for the first symptoms, and also use them as messengers to take public health information back to their families.

Rose: This was a really, really unpopular decision.

Laura: But in fact, they were vindicated, because most of the school aged children were spared that autumn.

Rose: In the end, New York City, despite being so densely populated, actually fared better than some other places in the United States. In fact, thousands of miles away, Alaska might have had it worst of all.

The Yup’ik people of Alaska, for example, didn’t even get the first wave of the flu, because the winter had frozen the port in Bristol Bay. But when the second and third waves arrived, the virus totally decimated the population there.

Laura:  The population, mainly Yup’ik Eskimo population of Bristol Bay, lost 40 percent of its numbers

Rose: At the time, Alaska wasn’t officially a state, so the US wasn’t all that keen on sending additional funds or resources to help the people there.

Laura: One government doctor, Linus Hiram French in the main town in Bristol Bay, Dillingham, was left to cope pretty much on his own, with two nurses, a couple of auxiliary nurses, and the doctors who were employed by the Alaska Packing Association, the salmon packing industry around the bay.

Rose: With no support, four in ten people in Bristol Bay died.

Laura: One of the oddities of this pandemic was that young children wer often the only ones spared. So there were many Eskimo villages around Bristol Bay where the only survivors were small children. So these children were rounded up and brought to Dillingham, where they were finally found to number around 300. Now, if you consider that Dillingham, at that time, was a town of 200 inhabitants; they had a major problem on their hands.

Rose: Eventually, the US government did send money to build an orphanage in Bristol Bay, to house all of these children. And most of those children, as they grew up, wound up staying in the Bristol Bay area, instead of returning to their native villages.

Laura: Today, the indigenous population of Dillingham all claim to be descended from those orphans.

Rose: In the Yup’ik culture they call the 1918 pandemic the Great Death, or the Big Sickness. The Yup’ik author Harold Napoleon wrote an essay in 1996 about how the pandemic impacted his family and culture, saying “The world the survivors woke up to was without anchor. The angalkuq, their medicines, and their beliefs had all passed away overnight. They woke up in shock, listless, confused, bewildered, heartbroken, and afraid.”

The 1918 Spanish flu killed somewhere between 50 and 100 million people. At the time, that was four or five percent of the entire global population.

Laura: Families were very often hollowed out. You remember that there was a middle age group, 20 to 40 year olds, which were particularly vulnerable. So that meant that families and communities lost their breadwinners, their pillars. And many, many dependent children and elderly people were left without anyone to provide for them. So old people went into poor houses in droves. Orphans were left very much to fend for themselves. Some of them were taken in by extended families. Some of them were put to work.

Rose: Even the unborn future generations felt the impact of this pandemic.

Laura:  There was a generation, in the womb, that was affected for its entire life long. Because we know that what happens to fetuses in the womb can affect their development. We know that that generation was diminished, physically, and to some extent cognitively. And that they were less likely, for example, to earn a good wage, graduate from university, and more likely to go to prison, more likely to suffer from heart disease after the age of 60. So that’s just another way in which the Spanish Flu cast a shadow, if you like, over the 20th century.

Rose: Many communities, whether they know it or not, are still living in the shadow of the 1918 flu pandemic. And now, 100 year after the 1918 pandemic, a lot has changed about the world. As of 2008, more people live in cities than outside of them. An airplane can take you across the world in a day. And places that were once remote, are no longer. The 1995 Ebola outbreak largely stayed in the town of Kikwit, in the Democratic Republic of the Congo. But that’s not a given, today.

Ed: Back in 1995, the road that connected Kikwit to Kinshasa, this megacity of millions of people, the capital of the Congo, was in such bad shape that it would have taken about a week to traverse. But now, I drove that road in eight hours.

Rose: That’s Ed again

Ed: And I think it shows that, as places become more developed, and as the infrastructure builds up, the dark side of that is that not only can people travel more easily. but diseases can as well.

Nahid: So, as we congregate in larger, tighter knit communities, and then we introduce potential things like increased need for protein. We then cut down wild forests and wetlands. And when we do that we introduce wildfowl, who are the carriers of avian influenza or novel flu, to our domestic animals like domestic birds.

Rose: And that’s Nahid again.

Nahid: And then, once that virus have jumped from a wildfowl into our chickens and hens and ducks, we then take those chickens and hens and ducks into the city to sell them, because we have a large population, and we want to feed everybody. So now that creates this area where the virus has increased chances of, basically, interacting between the between the bird and the human. And over time, and this is the big worry, that you’re going to get more and more viruses that adapt to humans, jump into humans. It’s something called spillover. The phenomenon of spillover, where the virus basically spills from animals into humans.

Rose: All this means that not only are new diseases more likely to pop up, but they’re also more likely to spread quickly across the globe.

Rose [on the phone]: I’ve read a lot that “it’s not if, it’s when,” is that true?

Nahid: It’s when. Yeah, it’s definitely. Let’s hope it’s not in our lifetime.

Rose: So what would happen when? Are we ready? Who is responsible for stopping a pandemic, and are they going to be able to do that? All that and more, after this quick break.

[AD BREAK]

Rose: Okay, so all of the experts say that a pandemic will hit us, sooner or later. But what happens next? Well, first we have to identify that a pandemic is even happening, and that’s actually pretty hard to do.

Nahid: That is actually one of the hardest questions to answer because all infectious diseases look pretty similar. During the Ebola outbreak, I volunteered in Ebola treatment units, and I always tell people that many of the Ebola patients looked like they were flu patients early on. You know everybody has nausea, vomiting, and fever.

Rose: And that’s if the pandemic is Ebola, or some other novel disease. If it’s flu, then there’s a question of when something goes from flu season to full on pandemic.

Nahid: Really, the importance of this is training our health care workers that when someone presents to our emergency room or our clinic, that we take a thorough travel history. That we know where they’re coming from and if there are any ongoing outbreaks there. That’s really what allows us to, sort of, identify the needle from the haystack, if that makes sense. Particularly during flu season, when you have hundreds of people coming through the emergency room. How do you recognize the one person who has a fever, who might be a returning traveller from somewhere?

Rose: Once a pandemic is identified, there are about a million decisions, big and small, that then have to be made. Some of those decisions are made by policy makers, everybody from the president to small town mayors. Other decisions are made by private companies, like hospitals and vaccine manufacturers. And then, of course, there’s the wild card of … us, regular people, and how we behave in the face of a pandemic.

Let’s start with the first part: how do the major governmental groups in the United States respond? It turns out, at least when it comes to the US, we know a little bit about what might go down during the next pandemic, because earlier this year there was actually a simulation to practice exactly that.

Nicky Twilley: It was hosted by the Johns Hopkins Center for Health Security. It’s the third of these kinds of simulations that they’ve done. This one was in a ballroom, at the Mandarin Oriental Hotel in D.C. So we were under these sort of glittering chandeliers.

Rose: This is Nicky Twilley. She might sound familiar because she’s been on the show before! She joined me to talk about exercise pills, and last season about calories and the quantified self with her podcast co-host Cynthia Graber from Gastropod.

Nicky: And I am co authoring a book on quarantine with Geoff Manaugh, who happens to be my husband, but also a great co-author.

Rose: Okay, so, back to the Mandarin Oriental Hotel in D.C. Under the glittering chandeliers, there was a U shaped table, and around that table are 10 people playing senior political figures during an outbreak.

Nicky: What’s interesting about them, is they’ve either been in the job they’re playing before – so you had the former director of the CDC playing the director of the CDC – or they are actually –  there was one current serving congresswoman that was a former deputy attorney general playing the attorney general. So, they were in their roles that they had been in.

Rose: And they were all there to go through a simulation for what might happen if a pandemic hit the United States. The disease they were presented with was dubbed Clade X, and they were given information throughout the day via fake news broadcasts like this one:

News Anchor: We are continuing our coverage of a new and deadly infectious disease that broke out in Frankfurt Germany and Caracas Venezuela two days ago. The World Health Organization responded by declaring a public health emergency of international concern a highly unusual step and an indication of its deep worry. Here are the numbers. In Frankfurt and Caracas the illness has killed an estimated 50 people. There are 400 confirmed or probable cases. With additional reports of suspected but unconfirmed cases the illness first appeared in Frankfurt… [fades out]

Rose: You can actually watch a recorded stream of the whole day online, if you want, and I will put a link to that in the show notes, but Nicky was in the room, observing how this Clade X pandemic might unfold.

Nicky: It was kind of a weird setup, because we were on stadium style seating, so it’ like you’re at a high school basketball game, except for half the world’s population is dying in front of you. So, kind of a weird setup.

Rose: So, as they get these news briefings, the 10 people around this table basically have to sort out what to do.

Nicky: I mean, it was totally fascinating. The guy playing the head of the Department of Defense starts shooting from the hip, basically, and as like, “one year to develop a vaccine is way too long. We need to do whatever it takes.”

Rose: Here’s Jim Talent, a former senator from Missouri, who was playing the Secretary of Defense, from the simulation:

Jim Talent: One year to produce a vaccine for this is too long. I think the president ought to make clear whatever it takes to shorten that period of time, we need to do.

Nicky: The scientists in the room are like, “we can do whatever it takes, it still takes a year.”

Rose: Here’s Margaret Hamburg, the former head of the FDA, who in this scenario was playing the Health and Human Services Secretary.

Margaret Hamburg: And let’s be careful not to over promise. I mean, already the discussion about vaccines is making me a little bit nervous, because there have been vaccines in development for many years. Doesn’t look like any of those are going to be effective against this. So let’s not get the American people thinking that if we just put more money, and rolled up our sleeves, we could get them a vaccine tomorrow.

Jim: Do you think twelve months is overpromising.

Margaret: I think we should be very careful. I think we should say it’s a high priority.

Rose: Now, you might be wondering, like I was while I was watching this: why does something like a flu vaccine take at least a year to make? One of the big things that I was actually really surprised by in reporting this episode, was that flu vaccines are still made in this incredibly old-school and not-very-efficient way.

Ed: So, I think people have this idea that we’re in the 21st century, we have very advanced medical technology, and surely there is a plant that cranks out vaccines in the same way that you would imagine a pharmaceutical drug was manufactured. And, in fact, making flu vaccines is much less like that kind of industrial manufacturing, and much more like growing a crop; there’s something weirdly agricultural about it

Rose: The way that flu vaccines are currently produced is using chicken eggs. Yes. Chicken eggs. I promise you I’m not making this up.

Ed: Mostly vaccines are still made using chicken eggs. Which is the same technique that has been used to make them for decades. So, you literally inject this egg with viruses. The viruses grow up in the whites, which are then harvested. And the viruses are purified.

Rose: And it’s not like this quirky system is actually really efficient. It’s not! Sometimes, the viruses evolve inside the eggs, so the vaccines you get don’t even work on the virus you’re trying to combat. Plus, eggs grow slowly! In 2009, it took months and months to ramp up the flu vaccine production.

Ed: The CDC director at the time, Tom Frieden, famously and wonderfully told the press, “if you scream at the eggs they’re not going to go faster.”

Rose: Plus, in the United States, there’s a supply chain problem, too. The US doesn’t have a national federal capacity for making flu vaccines. Most of the vaccines are made by private companies, and many of those companies are based in China. So, if there really is a global pandemic, depending on how bad it is, there’s no guarantee that the vaccines will wind up in the US for a long time, if ever.

And there’s very little movement to change this, because making flu vaccines, generally, just isn’t profitable.

Ed: It’s a bad business decision to make flu vaccines, which are incredibly low margin, and which the majority of Americans don’t want to use. So there is kind of a demand problem.

Rose: Plus, even if we did have companies in the US making stockpiles of flu vaccines right now, those vaccines quickly become useless.

Ed: The problem is that flu viruses change all the time. So, vaccines were made against the H7N9 strains that are currently circulating in China. That is the one that is at the top of this league table of of potential deadly strains. But, H7N9 has now changed enough that the vaccines that were made and that were stockpiled are no good anymore. So the whole process needs to be repeated, which is, on one hand, a phenomenal waste of money. But on the other hand, a very necessary thing that you need to do

Rose: To get around all this wasted, but necessary, effort and spending, there are some companies experimenting with better ways to produce vaccines. Like using dog cells instead of eggs to grow the viruses. Other people are working on trying to come up with a universal flu vaccine, so you don’t always have to play catch-up with the ever evolving virus.

Ed: I think that it’s going to be very difficult to get a truly universal one, that works across every possible type of flu. I think that maybe we’ll get there, but it feels like a very far away thing. But getting something that, say, works against all H1N1s would be huge. That would have prevented the 2009 pandemic. Getting something that works across or H5 or H7 flus would, at least, reassure us against some of the more worrying strains that are out there.

Rose: So yeah, if a flu pandemic hits, it might be more than a year before we get a vaccine. And remember, the 1918 flu pandemic only lasted a year, so… that timeline is not great! The next big question that the people in this Clade X simulation tackled was whether they should close down the US’s borders. A travel ban to keep infected people out.

Nicky: The guys were all like, “well we have to do this. We don’t want it to come to the U.S. Our priority has to be protecting the homeland.”

Rose: The problem is that the science pretty clearly shows that travel bans don’t work.

Nicky: And actually they’re counterproductive if you want to contain an epidemic before it gets out of hand. You need people moving in, actually. You need that freedom to bring doctors and nurses and medical supplies to the place that is having the outbreak, so you can contain it there. And a travel ban does not help that happen. Not only does it not work, you’re also shooting yourself in the foot, and making it more likely that it will spread. And you’re making it harder to track because folks will go around it, essentially. You set up a travel ban from Germany, well someone will fly to Denmark and then fly to the US, you know? So they made the logical argument against it.

Rose: And after hearing this logical argument against travel bans, the guy playing the head of the Department of Defense, Jim Talent, was basically like “okay, I am convinced, I see that this is true, but there’s \one problem: we can’t go out in front of the American people and tell them that we are not doing something.” So here’s what Jim Talent said in the simulation.

Jim: So, obviously we need a balance. I’m not talking about, you know, waving with our hair on fire. But, I would be careful about the messaging. I think they’ve got to see us leaning in. Plus which, maybe I’m too sensitive to the Congress, but if the president is seen as not taking vigorous action, they’re going to start firing from the Hill yesterday.

Nicky: And I thought, “wow, this is really helpful,” because I had known the answer to that question, as it were. I was like, “oh, I know the answer! I know the answer!” You know, when they said, “should we have a travel ban?” And I was like, “I know! We shouldn’t.” And actually,  by having that group of people at the table, it was suddenly really clear that we do know the answer, but we didn’t know that there was this kind of missing chunk in how to communicate it.  And if you can’t communicate it, it doesn’t matter if you have the right answer. So, I was like, “oh, this is why you do the simulation.”

Rose: We all hope, or at least I certainly hope, that in a time of crisis like a pandemic, the people in charge will make decisions based on what we actually know works and doesn’t work. But what the Clade X simulation showed was that, that doesn’t always happen. Even if everybody knows the “right answer” for what to do, politics and optics can get in the way. Here’s another example: later in the day the table was presented with a choice to make about who would get the first round of vaccines. There’s not enough for everybody, so you have to decide who gets them first.

Nicky: They were presented with two scenarios: one where the vaccine went to doctors, and nurses, and paramedics, and key workers who keep the infrastructure going, and members of Congress – as we all know that the country would fall apart without them – and that list was following the principle of when you’re on an airplane and they say, “put your own mask on first.” That was that list. The grownups who are running the show need to have the vaccine, then everyone else can have it.

And then, there was this other list that was: children get it, and pregnant women, a more feel good list, if that makes sense. But then there wasn’t enough for some of the key workers.

Rose: Again, this is a situation in which the scientific answer is that the vaccine should go to the people containing and working to control the outbreak. Because in the long run that means you’re going to save more women and children.

Nicky: But actually the table, having been sort of quite rational and scientific about other things, was like, “nope, we’ve got to give it to the children. Without the children there is no future, and also there’s literally no way that any of us are going to go in front of the American people and say, ‘your children are going to die, but key workers will be fine.’” So they actually decided to go with the fuzzy feelgood list.

Rose: But the table didn’t always go with the feel good thing that the public wanted. In one part of the simulation, they were informed that Jordan, an American ally, was on the brink of civil war as a Clade X outbreak was sweeping their nation. And they were reaching out to the US for help. So the question was: should the US go and help them? The table was also told that doing so would be a very unpopular choice, as most of the US public wanted the government to focus on the outbreak that was killing tons of people in the US.

Nicky: The experts actually pretty much agreed. “This is not good. We’re going to bring back cases. There are a lot of things to figure out, like if the soldiers get sick, do we bring them back or do we kind of treat them there? Even though we sent them there to get sick?” So there are a lot of logistical conversations, but they were all completely agree that despite public opinion being totally against sending troops, that we should send troops because they are our ally. We need this region. We can’t not be there for them. And I was astonished. You know, I know America loves to fight terrorism, but I would have thought sending soldiers to a place with a worse outbreak than us, during an outbreak, to defend against terrorists in the Middle East – which aren’t we tired of going to the Middle East at this point? – I was amazed.

Rose: Both the vaccine question and this Jordan question get at something that often isn’t part of the official disaster planning documents put out by agencies with long and confusing acronym names. And that’s this concept of “values.” If you watch the Clade X simulation, this is an idea that comes up a lot around the table. You hear a lot of these experts saying things like “that’s not who we are,” and “that’s not what America stands for.”

Nicky: It was like even if the right scientific answer is to behave in a certain way, if it’s not consistent with our values, then we’re not going to do it. And that needs to be factored into how we’re thinking through these pandemic plans too. Because if people are going to still behave in a way that is consistent with their values, rather than in a way that is the best way to limit the spread, you should put that in the models.

Rose: By the end of the Clade X simulation 150 million people had died, worldwide. Which is… a lot of people! But there was, I guess, one silver lining to this outbreak? By the end of the simulation, the US had actually nationalized healthcare. We don’t have time to get into that decision and the details, but patrons will get the full backstory on why a pandemic might lead to nationalized healthcare in the US in the newsletter. So if you go to patreon.com/flashforwardpod and sign up at the $2 level you will get to learn more about that.

This Johns Hopkins simulation really helped to highlight some of the areas where the United States is and isn’t prepared when it comes to the next pandemic. But the simulation also doesn’t exist in a vacuum. Nahid says that the recent Ebola outbreaks actually have helped the US prepare, in some respects.

Nahid: The good news is around the Ebola outbreak, right after it, HHS and ASPR, which is the Assistant Secretary for Preparedness and Response for these kinds of emergencies, put together this plan that said that we’re going to create these hospitals, these regional centres of excellence in the US, that are going to be leaders in trying to tackle such a pandemic, or you know outbreak. And then every other hospital is getting to receive a certain amount of training and funding to up their capacity. And that’s a good thing that’s happened.

Rose: For his piece in The Atlantic, Ed visited one of these kinds of biocontainment units4 in Nebraska.

Ed: The facility itself just looks like a normal hospital ward, but it’s been very cleverly designed to make sure that no viruses can escape, and that people with those viruses can be wheeled in and given the best possible medical care. So, for example, the whole thing is under negative air pressure. Which means that if you open the doors leading into the ward, the air flows in with you so viruses can’t leave. And likewise, when you open the doors to the patient rooms the air flows in with you.

Rose: These kinds of biocontainment units have to not only be able to keep the deadly pathogens in, but you also have to be able to clean them, once the patient leaves.

Ed: Say you have a patient with Ebola. They’re cured. They leave. How do you clean the room? Well, after wiping it all down with bleach, what you do is you wheel out this giant tower of fluorescent tubes which just bombard the whole space with ultraviolet radiation. And because viruses are so tiny even a dust mote can hide to them in a protective shadow. So what they’ve done is to paint the walls of all of these patient rooms in UV reflective paint, so that the light from these sterilizing towers will just bounce repeatedly across the place.

Rose: These are the units that will be crucial during the next pandemic. But there aren’t very many of them in the United States. In fact, there are exactly 144 beds that can do this kind of thing in all of the US.

Earlier in this episode we talked about the supply chain problems that might arise for a vaccine. But it’s not just vaccines that could be a problem. Everything from protective masks to IV bags can be impacted by a pandemic.

Ed: So we saw some of this in a more local scale quite recently when Hurricane Maria hit Puerto Rico. Puerto Rico, weirdly, is home to a lot of the manufacturers of IV bags. So when the hurricane hit, the supply of IV bags to other parts of the United States dried up. And so, a lot of places were forced to inject IV fluid with syringes instead. Which meant that there started to be a syringe shortage. And you get this kind of ludicrous domino effect, where when one supply chain problem begets another. And this extends throughout the entire whole healthcare system.

Rose: The thing is, being prepared for something that humans have ever been particularly good at.

Ed: One of the things that I realized when reporting this piece, and that I wanted to focus on, was that our attitudes to preparing for epidemics and pandemics is very cyclical. We panic when these crises are knocking on our doorsteps, but then we rapidly forget once they’re over. So, you’ll see investment in research rise and then quickly fall. You’ll see work on countermeasures or stockpiles of protective equipment to show the same pattern.

Rose: This isn’t just the case in the US, either. It happens everywhere.

Nahid: Every time there’s an Ebola outbreak, for example, because that’s one of the pathogens I work with a lot, you have to go and create an Ebola treatment center from the ground. And there’s always a delay, and there’s always cases of people who escaped because the quality of care is not as good, or there was a delay in care, or whatever it is. Right? And it’s happening in the same six countries since 1976, when Ebola was first discovered. So you go, “well why can’t we just have a few Ebola treatment units set up, that you can fund that get restarted if there is an outbreak in those countries?” You know that those are the countries that are at highest risk, right? But how do you sell that to a U.S. population. How do you say to U.S. politicians that this is worth investing in? When it’s not something that is in our country. Despite the fact there is already evidence that when there is an Ebola outbreak in West Africa, it impacts us.

Rose: For his story, Ed visited Kikwit, in the DRC. Kikwit was where the 1995 Ebola outbreak happened which killed 245 people. But when Ed visited, he found that while the memory of the outbreak is still very strong, the people there still aren’t prepared.

Ed: It’s inescapable to the people working there that this happened. They lived through it, and they’re still working there. One of the guys who survived the outbreak, and was showing me around touched the very same bed that he was sick on that, he was being treated in. Many of the people who were there at the outbreak are still there. But, I think, even though there is this sort of societal memory, the are still facing the same problems that we are facing in the States and that other countries are facing. This idea of forgetfulness and of gradual neglect. So, many of the resources that were set up and stockpiled to help protect people if another outbreak should hitm, they’ve been depleted now.

Rose: But I think that maybe the scariest thing in all of this, in watching the Clade X simulation, and talking to Ed, and Nahid. and Nicky, is that so much of our ability to respond and react and detect these pandemics – so much of whether or not we wind up with a thousand people dead or 150 million – comes down to something that’s increasingly precarious these days. And that’s trust in experts, trust in scientists. Budgets for science and public health are being slashed all over, and there are several crucial roles in the government, that might deal with the pandemic, that aren’t even filled right now.

Nahid: There is a recommendation by the White House that we cut the CDC’s Public Health Commissioned Corps by 40 percent. Think of them as our public health soldiers. These are the folks that investigate our outbreaks. That link the federal and the state health departments. If I see something suspicious, and I’m really worried, I call them, and they come and help a hospital, or a state, or things like that. If we cut that by 40 percent, we’re just shooting ourselves in the foot.

Rose: Plus, we’re in a moment where borders are tightening, foreign aid is drying up, the idea that we should help other nations is dwindling, at least among those in charge in the United States. And in the event of a pandemic, global cooperation is one of the most important things there is.

Ed: And I think it’s that ethic of cooperation, of working together towards a common goal, that we need to be striving towards. And I think ultimately that is going to be the thing that saves us. And I don’t mean just people looking after their neighbors. I mean an ethic of international cooperation, as well. I mean countries like the United States helping other countries in the world they don’t have the same resources to bolster their health systems. In many ways viruses are the one global threat.

Rose: There’s a trope in science fiction that aliens are what will finally bring all of us humanns together. A group of hostile and powerful beings descend upon Earth, and humans realize that they must set aside their differences and unite to fight them off. It’s a generally annoying cliche in science fiction. But when it comes to viruses, these dastardly dangerous things that live among us, it might actually be true. To save humankind, we might indeed have to band together and fight as one. The question is… whether we will.

Flash Forward is produced by me, Rose Eveleth. The intro music is by Asura and the outtro music is by Hussalonia. The episode art is by Matt Lubchansky. The voices from the future this episode were provided by Paul Krueger, Sean Raines, and Sameer Ajmani. If you want to become a voice in the future of Flash Forward, that is one of the rewards in Patreon for $10 and up patrons.

If you want to suggest a future we should take on, send us a note on Twitter, Facebook or by email at info@flashforwardpod.com. We love hearing your ideas! And if you think you’ve spotted one of the little references that I’ve hidden in the episode, email us there too. If you’re right, I’ll send you something cool.

And if you want to support the show, there are a few ways you can do that too! Head to www.flashforwardpod.com/support for more about how to give. But if that’s not in the cards for you, you can head to Apple Podcasts and leave us a nice review or just tell your friends about us. Those things really do help.