Pandemics and Globalization

Ring around the Rosie

Pockets full of posies

Ashes, ashes

All fall down

This is the song we would sing in the playground at recess when I was a child going to school in London in the 1950s. For us it was a tune that helped keep count while we were skipping rope, but what we didn't know was the origins of the tune.

It is now almost seven hundred years old, an eerie reminder of the greatest health catastrophe ever to strike mankind – the Black Plague. The rings refer to the red circles that would appear on the bodies of people suffering from the disease. The posies were to ward off the virus and to counter the smell of decomposing bodies that were everywhere. The ashes were the remains of the dead following the burning of corpses, a measure taken to prevent spread of the plague. Finally, 'fall down' was how children of the time would mimic the victims in their final hours, an attempt to make light of the horror occurring around them.

When people travel great distances they bring with them diseases to which they may have accustomed, but prove devastating to people who have not. That is human history, and it has been a constant force for the last ten thousand years. It goes in all directions and originates in every corner of the world.

What makes it seem like a more recent phenomenon is the fact that we only became capable of travelling long distances with the development of technology, starting with the ability to sail across large bodies of water in the last millennium before the modern age.

It turns out that diseases are regional, not global. They exist in some places, but not in others, as a reflection of differences of climate and ecology. As long as people travel within their region and not beyond, then infection and resistance occurs locally, and while the human cost may be high, it is contained and becomes endemic over time. It is still difficult to bear, but it is stable – not pandemic.

Think of it like this. There is a mushroom called the Death Cap which is lethal in almost every case, yet it is very similar in appearance to other mushrooms which are really delicious. Imagine how many early people died making this fatal mistake until they learned to distinguish between the deadly and the delicious by exchanging information over a wide enough area. We have no statistics about this, but just use your imagination to guess the extent of trial and error the human species went through before it developed safe behaviors.

Infectious disease works in this fashion. It may start in a region with a sharp outbreak marked by many deaths, but over time the human immune system develops a way of dealing with it so that even though it remains in the region, the price it exacts decreases over time as people adjust. They learn how to treat the disease more effectively, and genetically they develop natural ways of dealing with it. Religious leaders appear and rationalize the existence of the diseases as some form of punishment for bad behavior, and even though it still may kill, it does not exterminate.

A good example is the development of sickle cell anemia among indigenous African populations, which proves an effective resistance to malaria. While the disease is still endemic there, some groups have developed a genetic defense. It is still nasty, but it is contained, and the combination of more effective treatments developed over time together with genetic mutations to cope with the situation builds a certain level of tolerance.

No such response is available when the disease is exported from the area of inception to another area where it is unknown. In this case people have neither the treatment options nor the genetic adaptation developed over time, and they are massacred.

Smallpox, endemic in Europe but unknown in America, probably killed up to 90% of the indigenous Native American population within a hundred years of its introduction in the 16th century. Within a year of Hernando Cortes' arrival in the Aztec capital of Tenochtitlan in 1520, at least 40% of the city had died from smallpox. That story was repeated all over the continent for the next two centuries.

There are four great pandemics in modern history, and they all follow the same pattern:

The Justinian plague probably originated in Egypt in the sixth century, and moved from there to Constantinople with trading vessels, where it decimated the city before moving on with other traders into the heart of Europe. There is no way to accurately calculate how many people died from the disease, but a rough estimate is 30-50 million.

The Black Plague came out of Asia during the 14th century. Its inception is purported to have been in the Genoese trading port of Feodosia in the Crimea, where the Mongol army besieging the city catapulted infected corpses over the walls to infect the city's residents and force surrender. From there it was carried by Genoese trading vessels to Mediterranean ports, and eventually worked its way north in Europe as far as England and Scotland. Over the four year period of 1347-1351, it killed as much as a third of the entire population of Europe (as many as 150 million), reoccurring five times during the remainder of the 14th century and remaining endemic there after that, causing local outbreaks in particularly crowded cities like Lisbon and Marseille during the next three hundred years.

The third pandemic was the spread of cholera, which broke out in Yunnan China in the 1850s and travelled from there to Hong Kong with traders and from there on merchant ships all over the world, decimating cities as far flung as Cape Town, San Francisco, Bombay, Bangkok, and Guayaquil. Ten million people died.

The greatest pandemic in human history was the Spanish Flu that followed the First World War, a hundred years ago. It came home with soldiers from Europe who had been kept under horrific sanitary conditions in huge encampments to every corner of the world.By 1920, one third of the population if planet earth had been infected, and over 100 million people had died.

Finally, we have AIDS, which began in the 1980s and continues until this day in various parts of the world, principally Africa. It has, altogether, claimed more than 30 million lives.

This brief review is instructive because, while it shows a similar pattern of transmission in each case, responses to the catastrophes varied over time. In other words, while we humans obviously did not get smarter in prevention we did develop better tools for detection and treatment.

The Justinian plague went on for two years (541-542), working its way from Africa to Italy. The authorities in charge literally had no defense against it. It only ended when people learned to isolate themselves and many left the crowded cities for the country where it became clear over time that it did not spread as quickly. Historians today point to it as the last nail in the coffin of Roman hegemony in the world, and the real beginning of the middle ages. It brought down an entire empire.

When the bubonic plague reached England in 1349, Edward III, the king, understood that the main cause of infection was poor public hygiene, and ordered that burial pits for the dead be located far away from urban centers. He ordered the mayor of London to clean the streets. Venice closed its ports to incoming ships and those that did make it through were subject to 40 days of isolation, which later came to be known as 'quarantine.' When there was another outbreak, a century later, the mayor of London invoked this measure used by the Venetians, and the houses of those infected were marked with a blue cross.

Tellingly, nothing was done to halt the extermination of Native Americans, both in South and North America, by the introduction of smallpox from European conquerors, but by the end of the 18th century a first vaccine for the disease was developed in Boston, leading to a decrease in the number of victims in the 19th and 20th centuries.

During the plague of the 1850s, the British colonial government in India took measures to control the disease including quarantine, isolation camps, travel restrictions and the ban on what they considered ineffective local medical practices. Here, too, the situation was eased by the introduction of a vaccine at the end of the century.

Both European and American authorities stressed the importance of good ventilation and the avoidance of public crowding in treatment of the Spanish Flu, though, like the institutions that had come before them, they were overwhelmed by the sheer rate of infection. They knew what to do once it was there, but they seemed helpless to prevent its arrival. In America, saloons, dance halls and cinemas were closed and public funerals were prohibited. Both in Europe and America, protective clothing was employed for the first time when in contact with the sick, to be disposed of thereafter, and gauze masks became a routine feature of everyday life. This little rhyme was on posters all over the United States:

Obey the laws

And wear the gauze

Protect your jaws

From septic paws

So, as time passed, we identified, slowly, the three main elements that spread infection – long-distance travel, crowding and sanitation, and with each successive catastrophe we learned to take more effective measures to handle each of these. It should be noted that during this same period of time the influence of earlier authorities – e.g. the religious insistence that pandemics were God's retribution on a sinful world – became less and less influential in the management and treatment of disease. Science replaced religion; vaccines replaced flagellation.

The kinds of disease involved in pandemics varied over time. Smallpox, cholera, and the bubonic plague are different both in symptom logy and progress. Yet the underlying causes of pandemics remained constant throughout history – travel over long distances, crowding and sanitation.

 And another factor jumps out at you as you go over this history – time. While the Justinian plague and the Black Death needed years to spread, the Spanish Flu was present world-wide in a matter of months. This means that while authorities in charge in previous endemics had months to prepare their response, in 1918 the people confronting the Spanish Flu had a matter of weeks to respond, and that fact explains to a large extent the immense toll that the pandemic took. They were simply not prepared for the speed and size of the attack.

Now look at the pandemics that have occurred so far in the 21st century – there are five of them:

SARS

Swine Flu

MERS

Ebola

COVID -19

All five of these occurred in the space of less than 20 years. That's far more than at any other time in history. Now look at the gestation periods. SARS was first discovered in Asia in February, 2003. By July, five months later, the disease had spread to more than two dozen countries in North America, South America, Europe, and Asia. The swine flu first appeared in Mexico in April, 2009. By July it was all over North America and Europe, reaching as far as Turkey – a period of three months. The rest follow a similar pattern, and the latest, COVID-19, has spread from an initial outbreak in China in November to a complete global envelopment in a three month time frame.

Why? Because long-distance travel now is a matter of hours, the number of people travelling long distances has grown geometrically, and the destinations they travel to have multiplied. In 2004, just fewer than two million people made use of airline transportation. This year it is five million. It took Columbus 10 weeks to reach America. International flights now cover the same distance in 12 hours. There are now 1200 airports world-wide that handle international flights.

Think about it. If your aim is to contain the spread of a virus how can you do it when the number of independent travelers is in the millions, and they can choose between 1200 different places to carry a disease?

But wait! There is one more obvious pattern that emerges from the history of pandemics - mortality. The five pandemics of the 21st century together account for 200,000 deaths globally, numbers that bear no resemblance to the pandemics preceding them. While we clearly have not been successful in containing their spread, we have been much more successful in treatment. The medical response to pandemics is impressive. It may be nasty to contract a scary disease, but once you have your chances of survival are exponentially greater than those poor souls who succumbed to the Black Plague.

The challenge today for pandemics is not treatment, but containment. I don't know about you, but I travel a lot by air, at least a dozen flights every year for the last decade. How many times have I seen people sitting on airplanes when they are obviously ill? - Then that nice self-contained air circulation system in a sealed tube 30,000 feet above the ground distributes those germs equally throughout the plane (very democratic).

And how many people are denied air travel because they are suffering from an infectious disease? Here are the legal justifications an airline has to deny a seat to a passenger who has bought a ticket (in this case, United Airlines):

• Passengers who appear to be intoxicated or under the influence of drugs to a degree that the passenger may endanger themselves, another passenger or members of the crew
• Passengers who are barefoot or not properly clothed
• Pregnant passengers in their ninth month, unless the passenger provides a doctor's certificate dated no more than 72 hours prior to departure stating that the doctor has examined and found the passenger to be physically fit for air travel to and from the destination and that the estimated delivery date is after the date of the last flight
• Unaccompanied passengers who are both blind and deaf, unless the passenger is able to communicate with the representatives of United by other methods
• Passengers who are unwilling to follow United's policy that prohibits voice calls after the aircraft doors have closed, while taxiing before takeoff or while airborne
• Passengers wearing or possessing concealed or unconcealed deadly or dangerous weapons
• Passengers who are unwilling or unable to follow United's policy on smoking or use of other smokeless material
• Passengers who refuse to produce satisfactory proof of identification or those who present identification that does not match the name of the ticket
• Passengers who exhibit disorderly, offensive, abusive or violent conduct
• Passengers who fail to comply with or interfere with the duties of the flight crew members, federal regulations or security directives
• Passengers who assault any passengers or United employees, including the gate agents and flight crew
• Passengers who cause a disturbance such that the captain or member of the cockpit crew must leave the cockpit to attend to the disturbance
• Government request, regulations and security directives
• Failure to comply with the rules of the Contract of Carriages

You will notice that there is no mention of infectious diseases on this list. That is because the airline does not require passage of a medical examination or the submission of a 'bill of clean health' from a licensed physician in order to board a plane. In short, no one knows if the person boarding is carrying an infectious disease unless the symptoms are very pronounced.

All of this is left to the discretion of the individual traveler. It is analogous to leaving the decision to drive after consuming alcohol to the driver herself, thus relying on individual judgment. Have you ever consumed enough alcohol to make you unsteady behind the wheel, but you made it home safely anyway? That's the current medical check for airline travel.

The same is true of overcrowding, whether it is on an airplane or in a public place on the ground. The airport is a good start. If you have been to one on a day when a lot of people travel and flights are delayed, then you understand what a Petri dish that is for the spread of infectious diseases. The same is true of large concerts and sports events. No one is screening whether people that arrive at a football match are ill and therefore should be prevented from entering. It's up to them.

Finally, there is sanitation. Here great strides have been made since the days of the Black Death. The king may have had to beat the brow of the mayor of London to clean the streets but these days there is a city code that will fine people for not keeping their establishments sanitary, even close them down. Can you make people wash their hands if they don't want to? Well, the answer is yes, probably, but that is only by showing them the amount of disease they carry on their hands if they do not.

Imagine, for a minute, that each person entering a public place has to spray his hands with gel and then place them under a UV light, or breathe into a breathalyzer. Is this any more onerous than going through a door frame which detects if you have metal objects on your person, or being required to remove your belt and your shoes while going through security?

This curb on individual behavior is irritating but probably the way forward if we are serious about the goal of controlling the spread of infectious disease. It's all well and good to talk about the need for more hospital beds but if you go that far it is probably already too late, and we are no longer talking about containment. Once again, the challenge is to stop the spread of disease, not treat it once it has come.

The more we interact with each other globally, the more likely it is that we will see more pandemics like the five that have ushered us into this relatively new century. It is the cost of meeting people far away in large groups. What we can do along the way is become more responsible for the state of our own health before we make the journey, and turn this responsibility into a legal requirement. Do you need to get a license in order to operate a motor vehicle? Then what's so wrong about requiring a license indicating you have passed a medical examination in order to get on a plane?

Everyone has had a scare with this latest pandemic, but truth be told, the scare will taper off in a few months and then we will need to learn (it's easier to learn when you are not scared, but the problem is sometimes you lack the motivation). Clearly, as history is eager to show us, there will be more pandemics. That's the nature of our world, more so all the time. The question is not if, but when.

The present pandemic will have a tactical resolution within a few months. Eventually the rate of transmission will peak, and practices of treatment and isolation will have their effect, probably aided by a change in the weather. It will get better, and the level of panic will subside.

The historical question will then turn to the long term consequences. Every previous pandemic wrought immense changes in world history, many times acting as 'the final straw' to economic and social events that were already taking place.

As said before, the Justinian plague spelled the end of Roman domination throughout the world, ushering in what we call the dark or middle ages, characterize by a lack of central control and the de—unification of power throughout Europe. It set the continent back several centuries in terms of economic and social development, particularly as compared to China where dynastical control remained unaltered.

The Black Death, which wiped out a third of Europe's population, led to an economic golden age in the 15th century, where land was cheaper and wages rose because of a lack of laborers, probably laying the foundation for the Renaissance and redistributing wealth over the continent. It spelled the end of serfdom and a sharp increase in social mobility.

The cholera pandemics of the 19th century finally cemented the dominance of science over religion, and from this time forward scientists and engineers would become the new elite, replacing religious leaders in terms of importance and influence. It became the age of Pasteur, Lister and De lesseps, of canals, bridges and vaccines.

There is no question that the Spanish influenza was the result of the decisions of the great powers of the time to engage in a global conflict which could have been avoided, and those same powers paid the price. While no cause and effect connection has yet to be proved, there is no question that the spread of the pandemic coincided with the fall of empires in Germany, Austria, Russia, and Turkey.

So the question becomes, in the long term, what will be the global effects of the present pandemic?

The last decade, in particular, has seen ambivalence toward the impact of globalization, the idea of one world. Following the Second World War, the push was in this direction, led by global institutions such as the United Nations, and funded by the United States, which was the dominant player in this scenario (make the world safe for democracy).

But beginning with the millennium, particularly after 9/11 and the American adventure in Iraq, people all over the globe began questioning the move toward unification, and movement in the opposite direction started to take place, marked early on by the disintegration of Yugoslavia and Czechoslovakia, followed the Soviet Union. More recent moves toward dis-globalization include the Catalonian and Basque movements towards independence and now the Brexit of the United Kingdom. While there are still currents that pull us like a magnet toward one world, like global markets and technology, social temperatures are running high in the opposite direction.

Into this ebb and flow comes the new pandemic, just as the Spanish influenza appeared as the great empires in Europe were collapsing. The question is in which direction will the pandemic tip the scales?

Clearly, we are still in the early stages of the storm, and it will be a while before any clear indications arrive. But there are some provocative signs on the horizons.

The major social movement currently to cope with the pandemic is what is now being called 'shelter in place.' Originally implemented in Wuhan, the practice essentially means keeping everyone at home – i. e. – No one goes to work. The concept of gathering large numbers of people in a single space (office or factory) is stopped. People work from their homes. This has been proved to be very effective in interrupting transmission of the virus in China, and now that it has been implemented in California, it is likely that other countries will follow suit.

Will the practice increase movement toward globalization or toward decentralization? On the one hand, preventing mass gatherings suggests limiting interpersonal influence – no managers telling people what to do, no officers giving orders, no meetings by the water cooler or in the cafeteria.

But wait! We can't overlook the fact that social media has become the great engine of interpersonal influence during the last decade. What is Facebook, instagram and twitter if not evidence of that? So, just that we can't see each other (or more accurately touch each other) doesn't mean an end to interpersonal influence, it just means that it will take place in a non-hierarchical, digital structure. There will be fewer chains of command, or rather; chains of command will become digital, not physical. This is a concept already up and running, outlined in his book Team of Teams, by Gen. Stanley McChrystal.

We certainly don't need people to push stuff around anymore. Robots do most of that already, and people can exert their control over machines from a distance. There is no physical need for large numbers of people to gather together in order to produce.

That means that the pandemic may push into a new understanding of globalization, not as a union between disparate nations, but a relationship between individuals or small groups. Technology certainly makes this possible, but the global instruments of finance still bend toward large organizations, which stand in the way. If it becomes possible for small groups of people to interact ad hoc and find the financing to develop and market their initiatives globally, then you have a new road map for globalization, one that bypasses the concept of nationality and huge corporations, and forms a union between individual and world rather than nation, company and world.

The concept of 'big' is in question. Does it take an Apple to develop and launch a smart phone or can this be done by a small group of talented individuals across the globe, by passing the need for one company with 137,000 employees?

There is a famous Taoist story:

A farmer worked hard for many years. One day his horse ran away. His neighbor heard, and came over to tell the farmer how sorry he was that he had suffered such bad luck. "Perhaps," the farmer replied.

The next morning the horse came back, and following it were two more wild horses. The same neighbor came by to congratulate the farmer on his good fortune. "Perhaps," the farmer replied.

The following day, the farmer's son tried to ride one of the untamed horses, was thrown, and broke his leg. The neighbor came again to offer his condolences. "Perhaps," the farmer replied.

The day after, military officials came to the village to draft young men into the army. Seeing that the son's leg was broken, they passed him by. The neighbor congratulated the farmer on the good news.

"Perhaps," the farmer replied.

Like my youngest son is fond of saying, there are no tragedies, only opportunities offered to us by God. Let's hope we don't screw this one up.

Tony Gregory

March, 2020