Deadliest Enemy: Our War Against Killer Germs

When I was the state epidemiologist of Minnesota, a few people in the media started calling me “Bad News Mike” because often when public officials or corporate leaders got a call from me, I was unlikely to tell them anything they wanted to hear. In a story with that title by Kermit Pattison in Mpls St Paul magazine, the subhead read: “Headstrong and outspoken, the state’s epidemiologist insists he’s only a messenger from the germ front. Whatever he is, the message isn’t good.”

Well, I don’t know about the “headstrong” charge, but I certainly have to plead guilty to being “outspoken.” That’s because I believe in what I call consequential epidemiology. That is, by attempting to change what could happen if we don’t act, we can positively alter the course of history, rather than merely record and explain it retrospectively. Because of the accomplishments in the 1960s and 1970s of two of the giants of public health, Drs. Bill Foege and the late D. A. Henderson, aided by literally thousands of others, countless millions yet unborn will be spared the devastation of smallpox. Opportunities for such life-altering good are still out there, if we only recognize them and have the collective will to act.

This book results from my participation, observations, concerns, outbreak investigations, studies, programs, and policy development on the front lines of the major public health issues of our time. They involve toxic shock syndrome, AIDS, SARS, antibiotic resistance, foodborne diseases, vaccine-preventable diseases, bioterrorism, zoonotic diseases (those transmitted from or to animals and humans) including Ebola, and vector-borne diseases (those transmitted by mosquitoes, ticks, and flies, such as dengue and Zika viruses). Each experience or encounter—local, regional, national, or international—has informed and shaped my thinking, each has taught me a critical lesson about how we deal with our deadliest enemy, and each has focused the lens through which I approach public health.

Because, in fact, infectious disease is the deadliest enemy faced by all of humankind. True, infection is far from the only type of illness that affects each of us, but it is the only type that affects us collectively, and sometimes on a mass scale. Heart disease, cancer, even Alzheimer’s, can have devastating individual effects, and research leading to cures is laudable. But these diseases don’t really have the potential to alter the day-to-day functioning of society, halt travel, trade, and industry, or foster political instability.

If there is any particular theme to my career, it has been connecting disparate dots of information and making them into a coherent line to the future. For example, I both wrote and lectured as early as 2014 that the appearance of the Zika virus in the Americas was just a matter of time. Before a doubting professional audience at the National Academy of Medicine in 2015, I predicted that MERS would soon appear in a major city outside the Middle East. (It did, in Seoul, South Korea, just months later.)

I don’t claim any unique skills. Foreseeing issues and potential threats should be a matter of standard practice in public health.

When I established CIDRAP, the Center for Infectious Disease Research and Policy that I now head at the University of Minnesota, I was mindful of the fact that without policy, research has nowhere to go. Another way of saying this is that we tend to go from crisis to crisis without ever anticipating them or finishing the job in the end.

Science and policy must intersect to be effective. Therefore, throughout this book, we will seldom talk about realized or needed advances in the science of disease prevention without always giving equal consideration to what to do with those advances.

What we aim to give you here is a new paradigm for considering the threats posed by infectious disease outbreaks in the twenty-first century. While we will deal with the broad range of communicable illness, we will concentrate on identifying and exploring those maladies with the potential to disrupt the social, political, economic, emotional, or existential well-being of large regions, or even the entire planet. And while morbidity and mortality are certainly prime considerations, they are not the only ones. The current reality is that a few confirmed cases of smallpox anywhere in the world would create more sheer panic than do many thousands of malaria deaths in Africa alone.

That is, we don’t always make rational distinctions between what is likely to kill us and what is likely to hurt us, scare us, or simply make us uncomfortable. As a result, we don’t always make rational decisions about where to put our resources, where to direct our policy, and, frankly, where to direct our fear. As we write this, much of the Western world is greatly worried by the spread of Zika virus and its association with microcephaly, other birth defects, and Guillain-Barré syndrome. Yet over the past few years, dengue virus, which is spread by the very same mosquito, has killed far more people in the same region with hardly a blip on the public radar. Why? Probably because there are few situations as dramatic and horrifying as babies being born with small heads and facing uncertain lives of disability. It is every parent’s worst nightmare.

We will be invoking two metaphors for disease throughout this book. One is crime and the other is war, and both are apt because in various ways, our struggle against infectious disease resembles both of these horrors. In the investigation and diagnosis of outbreaks, we are like detectives. In our response, we must be like military strategists. Just as we will never eliminate either crime or war, we will never eliminate disease. And just as we engage in an ongoing war against crime, we are constantly battling disease.

In the first six chapters, we will present the stories, cases, and backdrop that will provide context for the rest of the book. From that point on, we will discuss what I consider our most pressing threats and challenges as well as practical means to take them on.

In 2005, I wrote an article for the journal Foreign Affairs entitled “Preparing for the Next Pandemic.” I concluded with the following warning:

In the eleven years that have passed since I wrote those words, I don’t see that much has changed.

We could try to scare you out of your wits with bleeding eyeballs and inner organs turned to mush as some books and films have attempted to do, but in the vast majority of instances, those images are a misrepresentation and not relevant. The truth and the reality should prove sufficiently concerning to scare us all into our wits.

I’m not trying to give either an optimistic or a pessimistic spin on the challenges in facing our deadliest enemy. I’m trying to be realistic. The only way we are going to confront and deal with the ever-present threat of infectious disease is to understand those challenges so that the unthinkable does not become the inevitable.