Now I got a job, but it don’t pay
I need health insurance, I need somewhere to stay
But without all of these things I can do
But without vaccines, I won’t make it through
But you don’t understand my point of view
I suppose there’s nothing I can do
I have been on a bit of a Clash binge of late. Truly one of the great rock bands.
I will confess I am not a fan of the current approach for the next epidemic, which is to do nothing. Well, not exactly nothing. Jay Bhattacharya, director of the National Institutes of Health, writes
Whether simply by stopping smoking, controlling hypertension or diabetes, or getting up and walking more, anything that makes the population healthier will prepare us better for the next pandemic.
Asymptotically approaching nothing but not quite there. The rest of our infection control approaches from the COVID pandemic appear off the table, from school closures to vaccines. It is time:
We must stop wasting money on the traditional playbook…The best pandemic preparedness playbook for the United States is making America healthy again.
Color me, well, skeptical.
This brings up a few issues I will randomly ramble on about.
It is the old battle: Pasteur or Bechamp. Germs or terrain. Infectious pathogns or the host. Well, it is both, to varying degrees depending on the infection. Forty years an infectious disease doctor and often responsible for infection control at multiple hospitals, I think it is often much more the germ than the host that is key. Sure, we can alter the host with immunosuppressive and invasive interventions that make it easier for some pathogens to cause disease. That is more the case for bacteria such as S. aureus and E. coli and fungi than it is for pathogens that are likely to cause the next pandemic. Those are much more likely to be viri.
I am not going to argue against the idea that it is better to be healthy than not when confronted by an infectious disease. I just don’t think being healthy is any close to enough to prevent infection, especially for viri. And brain worms.
There are many pathogens that have no problem infecting people, regardless of your metabolic health. HIV. Hepatitis A and B and C. Coronavirus. Influenza. Measles. And more.
What do these viri have in common? They use us to reproduce. They have evolved extremely efficient methods to infect us, multiply, and then move on to the next human, causing symptomatic disease and, on occasion, death. Viral reproduction will always win if there is no preexisting immunity, AKA vaccines.
The next pandemic, like the viri above, will likely also have a specific and efficient method to reproduce, some human molecule or receptor it will bind to start its reproduction. And I would bet, like the infections above, its drive to reproduce will overcome any host metabolic health. Infection is their raison d etre.
I also wonder, as an aside, it Bhattacharya et. al. would like to apply the same approach to, say, surgical infections. Doubt relying only on metabolic health would prevent hospital-acquired infections. I realize that a pandemic by a novel pathogen is not the same as preventing hospital acquired infections, but there is a lot of overlap in the techniques used to prevent both. The old playbook mostly works.
I thought it was interesting that they pointed to Sweden:
Sweden, without lockdown or school closures, was the best in the world at protecting human life during the Covid pandemic.
Before COVID hit, there was a large literature concerning influenza and school closures. And school closure was effective in controlling outbreaks.
The mean reduction of the peak of the epidemic was M=29.65%. Implementing school closure before or after the epidemic reaches its peak reduced the overall influenza epidemic. School closure reduced and delayed the epidemic peak, especially if implemented earlier. The longer the duration of closure, the more the epidemic peak delayed. Additionally, closure containment effect also correlated with organisms having high attack rates and longer infectiveness duration.
So for COVID, not a bad idea? Turns out COVID was not influenza and school closures may not have done much to slow down the epidemic. Likely did save some teachers from dying. But the incidence of many other infections declined dramatically and one strain of influenza went extinct.
An unusual and tangential outcome of the COVID-19 pandemic has been the apparent extinction of one of the four circulating varieties of human influenza viruses, known as the B/Yamagata/16/88-lineage (B/Yam) viruses
So who knows with the next pandemic. If it is more like influenza than COVID, the old play book would be just the thing to control it.
It appears there are several unspoken concepts behind the idea that being metabolically fit is all you need.
One is that by eating ultraprocessed fruit, we have been banished from the garden perfect health. That our baseline should be healthy. Nope. Our baseline, before the advent of sanitation and vaccines, is to be riddled with disease, infectious and otherwise.
There are a tremendous number of diseases that will be neither prevented nor cured by metabolic perfection. Type 1 diabetes. Cancers. Lupus. And many others. When the next pandemic hits, for those and other diseases, the old play book will be of more benefit to prevent infection than metabolic fitness.
Another assumption seems to be the idea that everyone shares the same immune system. We don’t. Variation is the clay that evolution molds and the immune system has too numerous to count variations that increases or decreases your response to infection.
Influenza deaths may be genetic:
A heritable contribution to the development of severe influenza virus infection (i.e., that which results in death) has not previously been hypothesized or tested. Evidence for a heritable contribution to death due to influenza was examined using a resource consisting of a genealogy of the Utah population linked to death certificates in Utah over a period of 100 years. The relative risks of death due to influenza were estimated for the relatives of 4855 individuals who died of influenza. Both close and distant relatives of individuals who died of influenza were shown to have a significantly increased risk of dying of influenza, consistent with a combination of shared exposure and genetic effects. These data provide strong support for a heritable contribution to predisposition to death due to influenza.
You lack a chemokine receptor. Congratulations. You cannot get HIV from sex. But you are more likely to have a bad outcome from West Nile. What evolution gives, evolution takes away.
There are innumerable polymorphisms, single amino acid variations, that increase or decrease infection risk and disease. My favorite is having the wrong snot:
A mutation in SPLUNC1 affecting mucosal attachment, biofilm formation, and invasion of mucosal epithelial cells is a new genetic cause of meningococcal disease.
The fault, dear Brutus, is not in our stars, / But in ourselves, and no attempt at metabolic fitness will alter whatever genetic predisposition, beneficial or otherwise, to disease you have.
Any response to the next pandemic should depend on the pathogen. The mode of transmission. What receptor/physiology it hijacks. The virulence of the organism. When the next pandemic starts, what to do will be uncertain. What kinds of infection control interventions will work? Can a vaccine or medication be rapidly developed? And at the beginning, when the fog is thickest and uncertainty at maximum, those tasked with controlling the pandemic will have the option of doing too much or too little. Pandemics are not porridge; there is never the option of getting the response just right. I would prefer doing too much but it looks like doing next to nothing is the current approach.
Relying on metabolic fitness is Darwinian survival of the fittest.
When I was young, I was impressed with the explanatory power of the Peter Principle:
The Peter principle states that a person who is competent at their job will earn a promotion to a position that requires different skills. If the promoted person lacks the skills required for the new role, they will be incompetent at the new level, and will not be promoted again. If the person is competent in the new role, they will be promoted again and will continue to be promoted until reaching a level at which they are incompetent. Being incompetent, the individual will not qualify for promotion again, and so will remain stuck at this final placement …And when someone reaches the highest level in their organization and yet is still competent at that level. This is only because there were not enough ranks in the hierarchy, or because they did not have time to reach a level of incompetence. Such people often seek a level of incompetence in another hierarchy.
Sound familiar? But wait (which I always hear as butt weight). There’s more.
Where the Peter Principle failed are the situations where incompetence itself is the reason for promotion to positions of authority. And that being incompetent in one hierarchy is the reason for a job that allows incompetence in another hierarchy.
Bright side? We only have to be lucky for three years and a month. Hear that bird flu? Extensively drug-resistant tuberculosis? Any other organism with pandemic potential? I know you are tempted by this wide open ecological niche with little protection you can subvert to reproduce, but hold off just a few years.
In the mean time, coffins look to be a good investment.