We Are All India and Brazil

I became fascinated by microbiology early in college. I trace my career in infectious diseases to this. I read Barbara Tuchman’s A Distant Mirror: The Calamitous 14th Century when I was an ID fellow; its 5th chapter was described as the single best description of the Black Death in Europe, the second of the three great plague pandemics. And so I became hooked on the history of medicine, the history of epidemics, and epidemiology. It took me a while but I finally received a Masters in Public Health as the natural outgrowth of this.

A common question posed of epidemiologists and public health people prior to 2020 was, What pandemic disease do you most fear? The overwhelming answer was influenza. Influenza has caused multiple pandemics. The 1918 “Spanish Flu” is perhaps the best remembered, although the name elides past its true genesis somewhere on the Western Front in France or in an Army camp in Kansas. Deaths from influenza surpassed deaths from the Black Death. I spent the final 11 years of my professional life in work on vaccines with a heavy emphasis on influenza vaccines. The fear of influenza is well-grounded.

Then came 2020 and an entirely different virus emerged in SARS-CoV-2. Its origin remains obscure but the geography pins down Wuhan, China. For reasons that will be written in history books of the future, humanity did a poor job in containing Covid-19. The United States became the epicenter of the pandemic as 2020 progressed. Vaccines, including the new type using mRNA, were deployed in December 2020. The United States as I write has given over 146 million doses of vaccine to its people (44.6% of our population) and counts 103.4 million people fully vaccinated. We have reached the point where vaccinations are sadly falling; the vaccine hesitant group is still to be convinced. Hospitalizations and deaths from Covid-19, except for several hot spots in the U.S., are slowly falling. Thus far the feared fourth surge has turned into a slowly falling plateau.

So, good news, huh? Well, no. Because this is a pandemic and other countries have seen a literal explosion of cases. India is experiencing morbidity and mortality that seems to parallel the 1918 flu pandemic. From an apparent low in March where the health minister declared an endgame, India now exceeds 300,000 officially reported cases each day and has so many deaths that improvised funeral pyres are necessary. Crematoria closed because they were damaged by the rapid rate of use. And experts argue that the numbers are really gross underestimates. Ashish Jha estimates the true numbers are 3X to 5X higher; the Institute for Health Metrics and Evaluation estimates India will peak at over 12,000 deaths per day by 20 May. 

Brazil is also in the midst of exploding cases, hospitalizations, and deaths from Covid-19. While not as high as India’s, Brazil has had 14.7 million cases with 406,000 deaths. But Brazil has only 15% of the population of India. What has led two nations of this size to such a catastrophe. Both Modi in India and Bolsonaro in Brazil have demonstrated competence issues over their time in office. Bolsonaro is an autocrat who admired Trump. Like Trump, he has a disdain for science and antipathy for facts. Modi is a Hindu nationalist. Observers have said he is more interested in winning elections than governing, something we also experienced in the U.S. during the reign of Trump. Massive political rallies in both India and Brazil and religious gatherings as well presented SARS-CoV-2 a perfect environment to spread quickly. This was also likely fueled by variants in both nations that are more transmissible. 

The end-result is exactly what plays now on our televisions, computers, and smartphones. Despite the idea that globalization is bad, it is real. No place on Earth is really more than one day apart. In 1347, it took months for plague to come from Crimea to Italy. The 1918 flu pandemic was spread everywhere by trains and steamships within weeks. Now, days. We are on Spaceship Earth and distance has shrunk to a single day. And what happens in India and Brazil and all other countries is really next door. As Vidya Krishnan points out in The Atlantic, no single person or government is responsible. Tragedies occur to all of us and because of all of us. Humanity has a great deal of work ahead to deal with Covid-19; we in the U.S. should not be relaxed, even though our fortune is better than others. A real question is will we learn the lessons -- or, as in 1918, just forget them because it is easier to move on?