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John Barry: The Pandemic Risk

How big a threat is it? How much should we worry?
Monday, July 30, 2018, 4:15 PM

As far as existential threats to the human species go, pandemics rank near the top of the list.

What's the probability of an agressive, highly-fatal outbreak occuring soon? Is it high enough to worry about?

And if one occurs, what can/should we do to protect ourselves and our loved ones?

To address these questions, we interview John M. Barry, author of the award-winning New York Times best-seller The Great Influenza: The Epic Story of the Deadliest Plague in History. John was the only non-scientist to serve on the US government's Infectious Disease Board of Experts and has served on advisory boards for MIT's Center for Engineering System Fundamentals and the Johns Hopkins Bloomberg School of Public Health. He has consulted on influenza preparedness and response to national security entities, the George W. Bush and Obama White Houses, state governments, and the private sector.

His verdict? The risk of a massively fatal world-wide pandemic like the 1918 Spanish flu is remote, but very real -- and is heightened by the hyper-connectedness of our modern society (i.e., the ease and speed with with people can travel). And our readiness for such an outbreak is woefully lacking:

An often-overlooked part of the damage a virulent pandemic can do is its impact on supply chains and the economy.

If you’ve got 20 to 30% of your air traffic controllers sick at the same time, what's that going to do to your economy?

Most of the power plants in the United States are still coal powered. They get their coal, most of them, from Wyoming. You see these enormous trains – that's a highly skilled position, the engineers who move those trains which are a mile and a half long. Suppose they're out. You're not going to have power in many of the power plants.

These are things that we don’t automatically think of as relating to a pandemic. Even a mild one that makes a lot of people sick without killing them will wreak an economic impact.

In terms of the health care system, practically all of the antibiotics are imported. If you interrupt those supply chains then you start getting people dying from diseases that are unrelated to influenza that they would otherwise survive. We had a small example of that with saline solutions bags which were produced in Puerto Rico. Because of the hurricane, Puerto Rico was no longer producing them; so we had tremendous shortages in those bages after the hurricane. Other suppliers worldwide have picked up the slack, so that's not a problem today.

But in a pandemic, you're going to have supply chain issues like that simultaneously all over the world. So you're not going to be able to call on any reserve, anywhere, because everybody's going to be in the same situation whether you talk about hypodermic needles or plastic gloves -- any of that stuff. The supply chain issues in a moderate pandemic are a real problem. If you’ve got a severe pandemic, the hospitals can't cope. There are many fewer hospital beds per capita than there used to be because everything has gotten more efficient. In this past year's bad influenza season, many, many hospitals around the country were so overwhelmed they all but closed their emergency rooms and weren't talking any more patients for any reason.

There's just no slack in the system. What efficiency does is eliminate as much as possible what's considered waste, but that waste is slack. And when you have a surge in something, you need that slack to take care of the surge. If I were grading generously I would give us a D in terms of overall preparedness. If we had a universal influenza vaccine, maybe we'd be relatively okay, but we don’t.

Click the play button below to listen to Chris' interview with John M. Barry (56m:47s).

Transcript: 

Chris: Welcome, everyone, to this Peak Prosperity podcast. I am your host, Chris Martenson, and it is July 23rd, 2018. Now, look, I know that these days there's no shortage of things to worry about or concern yourself with, and I'm not seeking to add to that list. I simply want to reshuffle the priority, maybe, so that you are focused on the right ones in the right order. Unfortunately, the Western media does a spectacularly good job of getting people to worry about the wrong things in the wrong order. Things that are of absolutely no importance to your life or potential future are placed at the very top of the national concern list while things that are actually very troublesome and deserving of our collective highest attention and your own personal attention somehow get excluded almost entirely from the conversation.

As a reminder, my PhD is in neurotoxicology from Duke, but there's no department of neurotoxicology at Duke, so my degree was housed within the department of pathology. So I took all the usual course for that, including microbiology, which includes the study of pathogenic bacteria in viruses. Now, the 2017 to 2018 flu cycle was a bad one for the world and in the United States; the worst in a decade, with many more deaths from the flu than usual, but also, still very far from the worst flu season on record. Several orders of magnitude away, which remains, of course, the 1918 flu epidemic.

Today's guest is John M. Barry, the author of the fantastic book, The Great Influence, the story of the deadliest pandemic in history, an accounting of the Spanish flu of 1918 which killed more people in 24 months than AIDS killed in 24 years. John is the author of four previous books including Rising Tide, The Great Mississippi Flood of 1927 and how it changed America. A book so well researched and written that John has considerable influence on both pandemic policy and flood protection. He lives in New Orleans, and we're talking to him today from Washington, D.C. Welcome, John, it's a real treat to have you on the program with us today.

John Barry: Well, thanks very much. A pleasure to be here. I kind of blew that. Let's start over.

Chris: Welcome, John, it's great to have you on the program with us today.

John Barry: Thanks very much. A pleasure to be here.

Chris: Listen, John, I want to jump straight in, right here, right at the top. What is a pandemic? What's the definition, and what's the chance of the world experiencing another pandemic say in the next five years?

John Barry: Well, a pandemic is simply a worldwide spread of an infectious disease, as opposed to an epidemic, which is localized or regionalized. The odds in the next five years are impossible to calculate. We've had multiple pandemics in terms of influenza. There have been at least twelve in the last 300 years. Sometimes they come eleven years about, sometimes they’ve come 40 years apart. There could be a pandemic that's already started that we don’t know about. It might now be for another 100 years. It's totally random.

Chris: When we're talking about a pandemic, I think we're usually talking about viruses, not bacteria. Is that absolutely correct, and how do you explain to people the difference between virus and bacteria because I know sometimes people get the microbiology a little confused at times?

John Barry: First, of course, the bubonic plague in the Middle Ages would certainly qualify as a pandemic, and you know better than I that it was a bacterium. It is one that today we can control, so it's a threat in local outbreaks, but, in general, it is certainly not a pandemic threat. Bacteria is a living organism. Virus is sort of on the edge of life. It doesn’t really do anything except reproduce itself. It doesn't eat, it doesn't have sex, it doesn't expel waste, it's just one integer or one increment above a chemical, really. It needs another cell to replicate. It invades another cell, whether it's one in our bodies or, for that matter, it could invade a bacterium, and it takes over the cell's manufacturing processes to make more viruses.

Chris: Great description. I remember we got into some debates back in school about is a virus a living thing or not. But it's a piece of genetic code. It's got a capsule. That generic code be MRNA, it could be DNA, and it goes in and checks that into a cell, takes over the machinery, off it goes, and just makes more of itself. I love how you described it; it doesn't eat, it doesn't excrete, it just makes more of itself.

And, of course, the bacteria that were responsible for the bubonic plague – we would put bacteria to tuberculosis, we would put it into leprosy – there are a few things out there. But viruses, those are the ones that really sweep through, create the flu. the flu often killing people because it takes over your machinery to an extent that you die from pneumonia or some related thing like that. So let's talk about the 1918 pandemic. How did that start? How did it spread? Please take us through some of that gripping story, would you?

John Barry: Well, all end points of viruses, all of them, have a natural reservoir in birds. So in a way, they're all bird viruses. But it's one of the fastest mutating viruses in existence. And that mutation rate – I'll give you one example. When a single influenza virus invades a single cell, generally, from six to twenty-four hours later when that cell explodes it will expel between 100 thousand and one million viral particles. I call them viral particles, not viruses, because it mutates so rapidly that 99 percent of those particles cannot function as a virus. They're incapable of infecting another cell.

That still leaves one percent, anywhere from a thousand to ten thousand from that cell which can infect other cells. But that mutation rate will give you an idea that every single permutation of that virus will be produced. So, if that virus randomly comes – if a virus that is capable of infecting mammals or humans comes in contact with a human cell, then that's one way the virus can jump species. But the more common way is the virus has been around for a long time. It infects essentially every mammal. Pigs happen to have receptors which combine both to human influenza viruses and to bird viruses. So, if a human virus and a bird virus happen to infect a cell in a pig, or it could happen in another mammal, as well, but pigs are particularly susceptible, then the virus can swap chains.

One of the things that's unusual about the influenza virus is instead of its genetic information being carried on a continuous strip of genetic material, there are actually eight separate segments that carry the genetic information. So, if you get two different viruses infecting the same cell, these segments – imagine shuffling two different decks of cards, and shuffling them together, and counting out one new deck, then you can create a new virus. And that could be one that would be capable of binding to human cells and also have enough of a different virus that it would be essentially invisible to the immune system. And those are the two ways you get pandemic.

So you get a new influenza virus infecting a human population when the immune system has not seen that virus before and is not prepared to naturally fight against it. So it will spread very explosively, much more explosively than seasonal influenza.

Chris: So, John, what happened in 1918, then? And I understand the story, it's thought to have begun in Kansas. What happened there, and what kind of a virus was it? How is that one classified?

John Barry: Well, it's a good question. We don’t really have the answer to it, even now. I think at this point – I was one of the earliest advocates of a Kansas beginning, but I'm not sure I feel that way myself anymore. A book came out fifteen years ago, there's been a lot of work since then, and I'm not convinced of Kansas at all. But nobody knows where it did begin. It could have begun in Kansas.

The latest work suggests there are eight segments in the virus, each of which carries – there are more than eight genes, but not a lot more. The latest work suggests that seven of those eight segments came immediately from a bird virus and that the eighth segment was a little bit older than that. So it wasn't quite entirely a bird virus that jumped to humans. There was some mixing, probably. But again, that's not conclusive. That's only the latest work, and that could be proved wrong tomorrow.

So one of my best friends and influenza experts, Mike Oshom, puts that he knows a lot less about influenza today than he know ten years ago. There's been a lot of work, and a lot of the things we thought we knew have proven wrong, actually.

Chris: Isn't that they way of the world? I know a lot less than I used to, as well, for the same reason. The more we learn the more confusing, the more elegant – I don’t know how you want to put it. It's astonishing. But in 1918 this virus really spread and it swept through the world. Do we know how many people were killed, and also, just a fascinating part of the story is who it claimed as its victims. Take us that that.

John Barry: Right. Well, first, the death toll was horrific. Probably the lowest modern estimate is 35 million dead, and I think there's been a general consensus that it's at least 50 million, it may have been 100 million. So, if you adjust for population, that would be the equivalent to 225 million to 450 million people killed today. It's amazing, and plus, most of these people died in a matter of probably roughly about sixteen to twenty weeks from September to early January. September 1918 to early January 1919, just an incredibly short period of time. So it was a very, very intense experience.

Unlike seasonal influenza, which tends to kill the elderly, chiefly because they usually have weaker immune systems, this virus killed otherwise healthy young adults. Probably about two-thirds of the dead were somewhere between 18 and 45 years old, and those are people who normally do not die from infectious disease because they have the strongest immune systems. Hypothesis is that the immune systems themselves overreacted to the virus.

The immune system has many, many toxic weapons, and the battlefield was the lung. So in an attempt to kill the virus they tended to destroy the lung. That's one of the hypotheses as to why young adults died. There are others that get pretty complicated. That's, I think, the leading hypothesis. The symptoms could be horrific. You could bleed not only from your nose and mouth, but from your eyes and ears. There are reports from physicians that people were turning so dark blue from lack of oxygen in the blood – they refer to it as cyanosis – that they couldn't distinguish African Americans from Whites. That, of course, spread rumors of the black plague from the Middle Ages.

And part of the terror was when you first got sick you didn't know if you were going to have the same kind of ordinary influenza attack that we all recognize today or whether it was going to develop into a lethal form. Plus, some of the deaths were literally in a matter of hours. People were well in the morning, went to work, and died on the way home. It was a pretty terrifying experience.

Chris: And through all of that, do we have a sense of what the mortality rate is, that is of, say 100 people infected, how many of them actually died?

John Barry: Well, in the Western world where we have some decent statistics, the case mortality was probably – it ranged country to country and region to region, but in general, probably around two percent. That's a little bit misleading because it depended on what the demographic was. For example, Metropolitan Life Insurance had numbers that over six percent of all minors, not case mortality, mortality – over six percent of all the minors in the young adult, 18 to 45, died. Pregnant women, there are studies that showed between – case mortality between 21 percent and 71 percent for pregnant women.

In parts of the world that are referred to as virgin populations, people who had never seen any influenza virus, so their immune systems were totally vulnerable, they were totally vulnerable because the immune system didn't protect them, you could see anywhere from 10 percent to 30 percent of the entire population dead. In smaller villages, although some as large as three or four hundred, both in Africa and in Alaska, you occasionally found 100 percent mortality. Everybody died.

Now, probably in those cases they didn’t all die of the disease. Probably they all got sick at the same time, and there was nobody even to bring water to someone, nobody to provide any kind of service, plus the psychological stress of seeing everyone around you dying, so that probably counted for the 100 percent mortality as opposed to the virus directly.

Chris: Now, you're describing some fairly remote places, Eskimo villages and African villages with just a few hundred people. How did the virus get to these places? I assume that there had to be a human vector of transmission.

John Barry: Correct. At least in places like Alaska or Newfoundland, generally it was the mail. In Africa, I don’t know exactly who the vector – I don't know. In North America, you could actually trace it in most places to the delivery of the mail.

Chris: So were the particles able to survive on the mail, or was it that the mail carriers were bringing it themselves?

John Barry: Well, actually, it was generally the mail carrier, the individual. Because you can think you're perfectly healthy and still, before you have any symptoms you can infect someone else with influenza, unlike other diseases. For example, SARS. SARS threatened to become a pandemic, but at the same token, SARS you're not really infectious until you're really sick, and then you're flat on your back, incubated, and you're not walking around. Influenza in exactly the reverse. You're most infectious pretty early in the disease, and you can certainly cause other people – transmit the disease when you have no symptoms or very early in the symptoms before you get really sick yourself.

But the virus can, in fact, survive outside the body and, depending on the temperature and the humidity, it can go anywhere from a couple hours to certainly more than a day. But, again, that depends of temperature and humidity and what kind of surface it is.

Chris: In 1918, I'm going to guess we didn’t really even know what a virus was, and of course, this must have been one of the greatest medical mysteries of all time, and I'm sure very intelligent people working very hard to figure it out. How did they finally begin to contain it, control it and treat it? Because I've seen the pictures that it was just row after row of beds of sick people, if they did manage to get to a treatment area, so they were heavily concentrated. Of course, we had the troop carriers of World War I, all these reasons for people to sort of be in proximity with each other. How did they begin to combat this, or was there anything they could do?

John Barry: The truth is there wasn't anything they could do. The scientists at the time were a lot more sophisticated than I think most people today give them credit for. For example, they developed – even though they didn't know what a virus was, whether it was a really, really, really small organism just like a bacterium, or whether it was a completely different kind of organism, they called them filterable viruses because they could go through the smallest filters.

But they, for example, proved that polio was a viral disease in 1908, and had a vaccine that was 100 percent effective in prevented polio in monkeys by 1910. It wasn't until 1950s that we had a vaccine that could protect people.

Well, the discovery of precisely what a virus was came out of research that began on influenza. It didn't occur until the 1920s, a few years later, a guy named Thomas Rivers. In terms on controlling it, they didn’t control it. It basically burned itself out. There was very little they could do. They did try what today would be called social distancing, suggesting that people keep their distance and so forth and so on, close schools, things like that. I don’t think those things were very effective, and frankly, I think they'd be minimally effective today.

I was part of the planning process that came up with what are called nonpharmaceutical interventions. In other words, what do you do when you don’t have drugs and how to mitigate another pandemic. I'm relatively pessimistic as to how much impact they would have. They would do something, but they certainly wouldn't control the outbreak of disease. And then something like closing schools has a lot of repercussions in the economy and everything else. So, I think you would need a pre-lethal outbreak before it would make sense to even attempt to do something like closing schools.

Then you have questions as to whether are these 12, 13-year-old kids – are they going to go to the mall? Are they going to go play basketball with each other? Or are they just going to stay home? If they're going to go out meeting with each other, then you lose the benefits that you would have had, most of it anyway, from school closing. But that kind of stuff would do some minimal good. Again, it depends on how severe the disease would be on how much sense it makes to implement some of these things.

Chris: Well, I'm interested in some of those other steps, John, because I remember the SARS outbreak. And, if my recollections are accurate and perhaps any guide, I recall travel being impacted, I remember seeing pictures of empty malls, empty planes as people avoided public places, and even countries…

John Barry: And everybody wearing masks.

Chris: Frist, I want to know if masks do any good, but second, I've been screened for temperature two flu outbreaks ago when I was coming into another country that did such things. So they actually had a temperature portal that you walked through just to make sure…So anyway, could we not expect that those sorts of…

John Barry: There are diseases for which some of those things would make sense like SARS because, as I said earlier, before someone can transmit SARS they're generally pretty sick. I think for influenza they're absolutely useless. In fact, a good friend of mine was Assistant Secretary of Health and Human Services and responsible for planning things like what the US would do for pandemic, and at our US airports they didn't use any of those temperature things for two reasons. Number one, they're not necessarily accurate and, number two, they're not going to catch someone who seems healthy, hasn't developed the symptoms yet, but is already carrying the virus.

According to all the models, it doesn't really matter if one person enters – comes to a city and starts to spread the disease or if twenty people start. And the reason it as the virus reproduces itself so rapidly in just a few days. So there has been modeling that said if we were to close borders 99 percent effectively, then you would delay the arrival of a pandemic by two to three weeks. And if you were only 90 percent effective, it would only be a few days to a week, which is pointless.

In addition, the economic disruption you would cause would be astronomical. Just for an example, in 2009, when it first seemed to surface in Mexico I did a lot of media. People were asking me whether or not I supported closing the borders I always said absolutely no. Well, most of the chlorine that goes to water purification plants in the United States comes out of Mexico, and most of those plants don't have a very long supply. So if you cut off the chlorine, then pretty soon people aren't going to be getting drinkable water. People would be dying of cholera and so forth and so on. There are always these long chain of consequences to any action that you're going to take. You need to think through those.

So there are diseases where quarantine makes sense. Influenza is not one of them. I'll give you some specific data which unfortunately was never published. But there was a great pioneer epidemiologist named George Stouffer who ended up doing the first head of The American Cancer Institute, did the first epidemiological surveys of cancer. He did a study of 120 Army camps with anywhere from two or three thousand soldiers to sixty thousand soldiers. And ninety-nine of those camps imposed a quarantine, twenty-one did not. And he found no difference, not simply not a statistically difference, but no different between the camps that did and did not impose quarantine. That was statistically.

However, he actually went in and did a qualitative assessment in addition to the straight quantitative assessment and discovered that the camps that very rigidly enforce the quarantine did, in fact, have some impact on the disease spreading out and slowing down the spread of the disease. The total morbidity remained about the same, but the stress on the hospitals and the camp and so forth was a lot less. So that would be worth doing.

But the question is, if you cannot successfully quarantine the military camp in the middle camp in the middle of a war, how can you possibly quarantine a civilian society during peacetime? It's just not doable. So a lot of the social measures that people talk about in a – at best, they would just take a little bit of the top off of another outbreak.

Now, one of the things you said at the very beginning of the show, the introduction, was exactly right. That we often worry about the wrong things, and influenza is a perfect example. There's a lot of work that is ongoing to develop a so-called universal influenzae vaccine, a vaccine that will work against all influenza viruses. Earlier I said it's one of the fastest mutating viruses in existence, and that's why you need a different vaccine every year. Even so, the most effective vaccine we have ever developed for influenza is only 62 percent effective. Most of the time it's 30, 40 percent effective.

Now, about fifteen years ago, when West Nile first surfaced, we were spending more money on West Nile than we were spending to develop an influenza vaccine. The worst year in American history in terms of death from West Nile was about three or four hundred people killed, whereas influenza was killing between three thousand and fifty-six thousand Americans a year. And yet, we were spending more money on West Nile. It's just nuts where people set their priorities.

Chris: Well, exactly. A couple of clarifications in there then. When you say numbers like 75 percent or 36 percent effective, what does that mean? Does that mean that somebody who got it would be impacted less or that only 36 percent of the people, if that's the number, were protected?

John Barry: That's a good question, and what that number means is that you are less – if it's 40 percent effective then you are 40 percent less likely to get the disease than if you had not gotten the vaccination. It does do probably further good in terms of giving you some protection so that your illness will not be as severe as it might otherwise be. That's pretty hard to quantify, severity of illness. They do think it does cut down on severity, so that is another benefit.

The reality is so many people are getting influenza, and it is potentially lethal. As many as 56 thousand Americans die in a bad year for influenza according to CDC. so tens of millions of Americans get it. Even if it's only 40 percent effective, it is still well worth getting the vaccine, plus the additional benefit that you mention which is supposedly, but I don’t know, that it's quantified in terms of less severity.

Chris: So I want to get to a couple of key pieces here in the time that we have remaining, but to get there, I think I'd like your help in explaining something. When we're talking about flu strains, this comes up every year, H this N that, like H3N2. John, what do these letters and numbers mean?

John Barry: Well, those are the two molecules that stick out in the outside of the virus. The H is a hemagglutinin and the N is called neuraminidases. And there are 18 different subtypes of hemagglutinin and nine neuraminidases. So if you have an H1N1 virus, then that is type number one hemagglutinin, type number one neuraminidases. The thread out there at the moment that seems most worrisome is H7N9, which is a virus that's circulating in China and has about a 60 percent mortality rate.

We're obviously concerned that will become more transmissible between humans and could spark up a pandemic. Actually, in 1997, H5N1 surfaced. We were very worried about that. That still circulates and is still killing roughly 50, 60 percent case mortality, but there are a lot fewer cases of N5N1. That was here in 2004. When it resurfaced it was known as bird flu. H7N9 is also another bird flu. But, as I said at the beginning, all influenza viruses are really bird flu because they all start out in birds.

But the names of the subtypes are actually less concerning because the subtypes themselves. For example, the 1918 virus was H1N1, and the 2009 virus was H1N1. They shared some similarities, and yet the 2009 virus, if we didn't have modern molecular biology and modern surveillance, it looked like a mild influenza year, although it was a pandemic compared to 1918 where you had 50 to 100 million deaths and both H1N1 viruses. So that subtype is – I think you understand the point I'm making.

Chris: Sure. That 2009 H1N1, I remember that as swine flu, and the numbers I have on that it killed maybe 200 thousand people worldwide which, again, not overly bad as far as these things go if the United States alone was maybe 59 thousand was the number you quoted before.

But looking at this H7N9 that is circulating in China, and you mentioned these horizons, so I'm thinking of all the contact that we have now. If you imagine a farm, like you have all these farms all over the world, but in China in particular where you have all these geese and ducks and chickens and you’ve got all these pig farms. It just feels like that's literally a petri dish for allowing these viruses to run through their mutation patterns. There seems like there's a greater and greater chance of human, animal, bird flu virus sort of contact, and yet, 1918 was the year one of these things popped out. Is there some explanation for that, or was that just luck of the draw?

John Barry: Number one, you're right on both counts. There's much more possibility today and much more interaction today. But, number two, it was just bad luck of the draw in 1918. So both things are true. I think everybody was looking to Asia for the emergence of the next pandemic, and then it occurred in Mexico, although I think the first cases were actually identified in San Diego. Where the next one comes from, it's random. I think the only thing we can be certain of is that there will be another pandemic and another after that. It's the nature of the virus.

How lethal it is, that's unknown. Whether or not we will have a universal influenza vaccine before the next one hits, that's unknown. As I said earlier, there is a lot of work going on on that. It really started after the bird flu scare in 2004 and got another push forward in 2009. There's been enough work done on it to suggest that it is possible, more than possible, it's probable that we can eventually develop one. But what it would do would be it would target parts of the virus that don’t mutate much. You know, as I said a while back, 99 percent of the virus particles produced in a cell are not viruses. They cannot function. They can't infect another cell and reproduce, but that's because the whole parts of a virus have mutated, but that one percent – there is a certain element of the viruses that have to remain pretty constant or it won't work. So if you target those areas of virus with a vaccine, that's how you get a universal vaccine. It does seem probable.

Chris: It seems very hopeful, and we'll keep an eye out for that. In the meantime I'm wondering – I was a little shocked – you said that the overall mortality rate for the Spanish Flu of 1918 - two percent, but if you looked within subclassifications within the young and the healthy, within the immunologically strong, might have been six or seven percent. You just quoted a number for the H7N9 of ten times that, practically. So, if something like that came along, what would you personally do given that? How would you alter your life if any ways at all?

John Barry: First, let me explain why it's so lethal. The normal influenza virus that we are subjected to all the time, that virus will only bind to your upper respiratory tract. The 1918 virus combined both to your – because it binds to your upper respiratory tract, then it is easily communicable to other people – you cough, you sneeze and so forth. The 1918 virus combined both to cells on your upper respiratory tract, so it was easily communicable, but it also combined to cells deep in the lung. So when that happened you were basically starting out with viral pneumonia, which is not a good place to start.

The bird flu viruses, which are H5N1 and H7N9, they are not communicable between people because they can only bind to cells that are already deep in the lung. So they do not transmit from one person to another, but if you get sick, then you're starting out with viral pneumonia. So if there were a pandemic that would be caused by those viruses, it would have to acquire the ability to bind to the upper respiratory tract, as well. So you would probably have a situation similar to 1918 – it's not exactly hopeful, but the mortality rate would not be 50 or 60 percent. It would drop a lot lower than that probably in the range of 1918. But you're still talking about tens of millions and possibly several hundred million deaths. So that's beyond horrific.

Again, this would all happen in a period of a few months. It would take – again, a completely horrific situation. I don't know. That word understates. In terms of what I would do, if there's a vaccine available I would take it. There are a couple of antiviral drugs which have only modest effect, but they do have some effect. In terms of after you're infected, there is called oseltamivir – I probably blew the pronunciation – it would have to be taken very soon after you first have a symptom. If they're taken more than 48 hours after your symptoms, they're probably not going to have any effect, impact at all, but if you take them immediately they can be useful. They also may be useful prophylactically.

In terms of so-called social distancing, if you can completely sequester yourself from the rest of the world, then you can have a good chance of protecting yourself, but the sequestration has to be complete, and it has to be sustained for at least six or eight weeks. It would take that long, probably more than six weeks – at least eight to ten weeks – for the virus to burn through a particular community. At least that's what happened in 1918 and in other pandemics. It was kind of a rolling thing. It would come to one city, and somewhere between eight to ten weeks later would have infected everybody who's going to be infected and then move on. It would be difficult to avoid.

Chris: What about just a standard N95 dust mask? I see people wearing them in China.

John Barry: Well, an N95 I think can be useful, however, they have to be worn very well. You have to put them on properly for them to be effective at all. That's number one. Number two, they're not very comfortable. You start adjusting them and they lose their impact. Number three, you have to be very careful when you take them off. Most of the SARS deaths were healthcare workers. It is hypothesized that most of them infected themselves when they took off their, what's called PPEs, personal protective equipment, because they got a little careless.

The very first meeting we had on pandemic preparedness in terms of developing social distancing measures and so-called non-pharmaceutical interventions, what you can do when don’t have a vaccine or a drug to mitigate a pandemic – we had the infection control officer from the Hong Kong hospital who was most – it was the hospital with by far the best safety rate and the fewest healthcare workers infected. And he made a presentation that basically sounded like Vince Lombardi, blocking and tackling. It's all fundamentals. Everybody knows what to do to protect themselves, or at least all these professional healthcare workers knew what to do when they took off their equipment and how to protect themselves, a matter of primarily washing hands and things like that, but they got a little bit sloppy.

And what he did in his hospital was absolutely insist and rigorously monitor the standard safety precautions that every single hospital or modern hospital in the world is familiar with, but he made sure they actually did it. And just a little bit of casualness in how you treat these things, and they infected themselves. So in terms on N95 mask and the general population, if they're worn properly, which is not as easy as it sounds, and if they're disposed of or taken off properly, then they would provide some protection. But as a widespread measure for the general population it would be difficult. Worth doing but difficult.

And a surgical mask, you’ve got to differentiate between and N95 and a surgical mask. A surgical mask will be useless expect in one instance. And even in 1918, they were familiar with the fact that if you put a mask on somebody who's sick, then that will protect people around the sick person. Will a mother put a surgical mask on a sick child and make that child suffer a little bit more? I don't know, but if the mother is convinced it will protect other people in the house, including her other kids, then she's much more likely to do that. But in terms of walking around on the street, a surgical mask would be absolutely useless, in my view.

Chris: I completely understand that. And as part of my training I did a lot of work in clean hoods. So I did a lot of cell biological work, and I also worked with radiological materials. And as part of my training they would make us pipette things from little vials across. And one of the things we would do is we would pipette fluorescence, a super, highly concentrated fluorescent material. And so you'd do the very best you could. You'd pipette it very carefully and move from one to the next, and you're absolutely sure – I was certain, on my first few times, that I was absolutely careful; I hadn't spilled a thing. And then you get the black light out, and it looks like a crime scene in there. There's stuff all over the place. It's very, very difficult to operate in a clean way.

And so, what I came away with from that experience, though, was that I learned that direct touch was important, and so I learned to train myself if flu seasons, like if I put my hand on a banister or I get a doorknob, I will not touch my mucosal membranes on my eyes or my nose or my mouth before I've washed my hands. And I found I've had pretty good success keeping myself healthy, but it takes a real consciousness, and it's very difficult to do well and consistently if it's not your habit already. So that was sort of my experience with this is that I think that it is possible to limit your exposure, but you really have to know what you're doing, and you got to be careful with it,

John Barry: And you have to do it every time.

Chris: Every time. Every time. And this is just how serious this is, is that I was reading about two case studies. There was one hospital that had much, much worse infection rates post-surgery, and by the time they finally parsed it all the way through – I'm sure you know where I'm going with this, John – they'd discovered that they'd gotten sloppy with hand washing there in the hospital with the high infection rate. The hand washing for a surgeon, it should be the simplest, most routine thing you could possibly do, and still it's hard to maintain that, apparently. Blocking and tackling I guess.

John Barry: Some hospitals do it right. On that kind of thing, infections after surgery, I mean, there's no reason that every hospital in the country doesn't have a great rate. There are some very significant differences in some hospital infection rates. And there's no justification for that. It's just carelessness.

Chris: Absolutely. So if you were going to give sort of a letter grade or however you'd want to rate this, how do you think we – where does the world stand in terms of its readiness for its next pandemic?

John Barry: How about somewhere between an E and an F.

Chris: An F minus, maybe. All right, E and F. Why is that?

John Barry: Well, one thing we haven't even discussed is supply chains and the economic impact and so forth and so on. You know, outside the healthcare system, if you have your air traffic controllers – you’ve got 20, 30 percent of your air traffic controllers sick at the same time, what's that going to do to your economy? If you have – I think most of the power plants in the United States are still coal powered. They get their coal, most of them, from Wyoming. You see these enormous trains – you fly over sometimes – and suppose all those – that's a highly skilled position, those engineers moving trains that are a mile long, a mile and a half long. Suppose they're out. You're not going to have power in many of the power plants. Things that you don’t automatically think of as relating to a pandemic. Even a mild one that makes a lot of people sick without killing them, then you have the economic impact.

To get to the healthcare system directly, practically all of the antibiotics are imported, and you interrupt those supply chains and then you start getting people who are dying from diseases that are unrelated to influenza that they would otherwise survive. Or we had a small example of that with saline solutions bags which were produced in Puerto Rico, and Puerto Rico, because of the hurricane, was no longer producing them, so we had tremendous shortages since the hurricane last year in those bags. Other suppliers worldwide have picked up the slack, so that's not a problem today.

But in a pandemic, you're going to have supply chain issues like that simultaneously all over the world, so you're not going to be able to call on any reserve anywhere, because everybody's going to be in the same situation, whether you talk about hypodermic needles or plastic gloves, any of that stuff. The supply chain issues in a moderate pandemic where, again, a lot of people are sick but not necessarily dying, that's a real problem. If you’ve got a severe pandemic, the hospitals can't cope. There are much fewer hospital beds per capita than there used to be because everything has gotten efficient. And in a normal influenza season, or a bad one like last year, many, many hospitals around the country were so overwhelmed they all but closed their emergency rooms and weren't talking anymore patients for any reason.

There's just no slack in the system. And what efficiency does is eliminate as much as possible what is considered waste, but that waste is slack. And when you have a surge in something, you need that slack to take care of the surge. If I were grading generously, I would give us a D. In terms of overall preparedness, if we were to have a universal influenza vaccine, maybe we'd be relatively okay, but we don’t.

Chris: Well, in the absence of that, and part of thing that I talk to my audience about, is the need for self-reliance and being prepared and understanding that if the supply chain disruptions – if you mention that there's a six to eight week burn cycle as this pandemic sort of sweeps through a territory, if we lost twenty percent of our truckers, there would be food shortages and innumerable other things that would be predictable to predict, if global trade even stuttered for a week or two weeks, there would be all these ripples going through that would be impossible to predict, but some would be relatively straight forward. We would just have breakdowns in certain supply chains. The longer and more fragile and the more just-in-time they're sort of navigating their inventory stash at, you have no buffers, no reserves. So, I think it's incumbent of individuals to have their own reserves and ability.

And you raised a great point. I was in California this May doing our yearly seminar. And when I was there they were having their flu – it was sort of at the peak there. And the headlines in the local papers were about how the hospitals were triaging out into tents out in the parking lot that they had to set up. And that's just on a relatively ordinary flu cycle or worst in the last ten years, I guess. But still, when I look at the charts it doesn't'/t look that out of range, all things considered.

John Barry: Well, let me make my final point, I guess, also. I think the public health sector has a pretty good idea of what it should do if there's a pandemic. Even though I've been pessimistic in terms of how much impact it would have, the recommendations would have some impact, there's no question. But to get a political figure to pay attention to a public health professional, that is where there's a huge gap. We saw that in 2009, where countries were acting irrationally, not just in China. The Chinese health minister announced that it was a foreign disease – he was going to keep if out of China. The French wanted the European Union to cancel all flights to Mexico, an enormous economic disruption with virtually no benefit. There are other countries around where Egypt slaughtered basically ever pig in the country. You said that was called swine flu. We saw ridiculous political responses again in Ebola a couple of years ago.

So does anyone think, even if you have listeners who are Trump supporters, do they really believe that Trump is going to listen to a public health professional if there's a pandemic and take their advice, or is he going to do something from his gut that is very likely going to – like close borders and end up cutting off supplies of chlorine to water purification plants and things like that? And not just Trump. Again, we haven't really seen many rational responses when there have been threats from countries. And I think that's maybe the thing that worries me among the most. I don’t know about the most. There are plenty of things to worry about. But the gap between a politician who's actually making a decision and the public health professional who's trying to get him or her to make the right decision. We certainly didn't see that in Ebola, really in any country in the world.

Chris: Understood. And very well said. And everybody, we've been talking with john Barry, author of The Great Influenza, the Story of the Deadliest Pandemic in History, author of many other fantastic books. John, what are you working on next and what can we look forward to coming from you next?

John Barry: Well, it won't be out for a few years, but as you may know, Louisiana has lost roughly 2,000 square miles of land in the last 70 years or so. I live in New Orleans. I was on the post Katrina Levee Board. I'm very involved in those issues. So I'm writing a book essentially about everything that's gone into making the Louisiana coast disappear, and hopefully how New Orleans has a chance to survive, if it can survive. Things like that. Another cheery subject.

Chris: Absolutely, but very important. John, thank you so much for your time today. I really appreciate it as I'm sure all my listeners do as well.

John Barry: Well okay. You're very welcome. I enjoyed it. Thank you.

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13 Comments

davefairtex's picture
davefairtex
Status: Diamond Member (Offline)
Joined: Sep 3 2008
Posts: 5685
reducing severity of influenza with NAC

So I posted this a while back, but it might be relevant here.  In terms of "what can I do" to protect vs an influenza pandemic - and this applies especially for older people - there was a double blind placebo-controlled study done on influenza infection severity back in 1997 where half the study group was given 600 mg NAC, the other half, placebo.

Long story short, the NAC group got infected just like the placebo group, but 2/3rds of those infected just didn't notice, and the remaining group had symptoms that were about half as strong as the placebo group.

http://europepmc.org/articles/PMC1884975

NAC treatment was well tolerated and resulted in a significant decrease in the frequency of influenza-like episodes, severity, and length of time confined to bed. Both local and systemic symptoms were sharply and significantly reduced in the NAC group. Frequency of seroconversion towards A/H1N1 Singapore 6/86 influenza virus was similar in the two groups, but only 25% of virus-infected subjects under NAC treatment developed a symptomatic form, versus 79% in the placebo group. Evaluation of cell-mediated immunity showed a progressive, significant shift from anergy to normoergy following NAC treatment. Administration of N-acetylcysteine during the winter, thus, appears to provide a significant attenuation of influenza and influenza-like episodes, especially in elderly high-risk individuals. N-acetylcysteine did not prevent A/H1N1 virus influenza infection but significantly reduced the incidence of clinically apparent disease

 

The mechanism of action: NAC is a precursor required for the body to make glutathione.  When there is a bad outcome in a disease state, low glutathione usually accompanies it.  And as we get older, we make less glutathione.  Taking NAC raises the body's glutathione levels - other studies have shown that if older people take NAC, they can get their glutathione levels back to the 20s-30s age group.

My pandemic plan: use NAC; it won't protect me from infection, but my hope is that it might move me from the "people who died" group into "the survivors" group.  And of course there's the thought that I might actually have agency in such a situation probably helps out as well. 

Now hopefully all the real doctors here can chime in with their thoughts.  :)

sand_puppy's picture
sand_puppy
Status: Diamond Member (Offline)
Joined: Apr 13 2011
Posts: 2033
Flu in the crowded slums

I share DaveF's impression that excellent immune function is a main goal.  And will add that it is GOOD to be infected with the latest strand of communicable disease (but at a low dose).   An excellent immune function allows one to survive immune to that threat.    When a new variation of the virus comes around a few years later, partial immunity will already exist making that next infection milder as well.

In one of Isaac Asimov's space travel novels, the ship physician releases viruses into the ventilation system every Friday evening deliberately infecting the travelers to keep immune systems challenged and strong.

Can you imagine the devastating effects of a virus lose in one of the slums of Manila or Lagos?  Close proximity, inability to clean one's hands and feet, body to body touching, coughing in close spaces, feces and urine running in rivulets down the streets?

These pictures are taken from Pinterest "slums."

richcabot's picture
richcabot
Status: Silver Member (Offline)
Joined: Apr 5 2011
Posts: 226
Food

Having large food stocks reduces one of the main reasons to come in contact with large numbers of other people.  It would also mitigate the issue of reduced truck deliveries.

thatchmo's picture
thatchmo
Status: Gold Member (Offline)
Joined: Dec 14 2008
Posts: 476
Hand sanitizer?

I'm kinda guessin' those folks in the slum photos have some fairly robust immune systems....Aloha, Steve.

Uncletommy's picture
Uncletommy
Status: Platinum Member (Offline)
Joined: May 3 2014
Posts: 633
Globalization's achilles heel?

As for "food for thought", this was a real banquet. Chris, you packed a hell of a lot of stuff to consider in this interview. The speed and the "instanteous" nature of our world was brought home, BIG TIME! Our public epidemiological preparedness has always has always left me a little uneasy, especially, after knowing someone involved with the SARS outbreak some years ago. The world's supply-line dependency only confirms the importance of a resilient preparedness and response. Looking to government during these times is hollow comfort. While this site can be sometimes seen as "Cassandra-esque", it doesn't shy away from discussing real possibilities and the importance of these issues. Again, well done.

Uncletommy's picture
Uncletommy
Status: Platinum Member (Offline)
Joined: May 3 2014
Posts: 633
KugsCheese's picture
KugsCheese
Status: Diamond Member (Offline)
Joined: Jan 2 2010
Posts: 1469
Glutathione and Mold

CoreMed Science makes a Liposomal Glutathione in liquid and gel caps.  Removes biotoxins.   How about a podcast with Surviving Mold founder Dr Shoemaker?  

Humans also need viral substances to combat bacteria.   See this video 

There is so much humans don't know about ecological balance.  Be careful about eliminating influenza as it might be beneficial but we don't see it yet.   Educated guess: keeps innate immune system tuned up and eliminates the weak.   No free lunch.  

nedyne's picture
nedyne
Status: Bronze Member (Offline)
Joined: Jan 14 2012
Posts: 73
Respirator?

What is the best respirator to have in a pandemic? In the podcast they talk about N95 masks, but is that really the best one can aim for? Say if you just have to go out of the house.

I would assume Chris has already done the research, so I would greatly appreciate if he posted a link to the product he chose.

Carl's picture
Carl
Status: Member (Offline)
Joined: Jul 17 2008
Posts: 24
Transcript?

Is the transcript still being prepared?

Uncletommy's picture
Uncletommy
Status: Platinum Member (Offline)
Joined: May 3 2014
Posts: 633
sand_puppy's picture
sand_puppy
Status: Diamond Member (Offline)
Joined: Apr 13 2011
Posts: 2033
Powered Air-Purifying Respirators (PAPRs)

Disclaimer:  I don't have much personal experience with respirators, except to know that wearing surgical and N95 masks is quite uncomfortable for me, personally.  They fog my glasses impairing close vision and make me feel hot like I'm suffocating.  Most people do OK with them, but not me. 

The work of breathing is high in a surgical or N95 mask.  The human repiratory musculature is the force that presses air through the filtration membrane that is the the mask itself.  The exhaled air exits around the mask edges into the users face. This makes breathing hard work and elicits the "fear of suffocation" type of sensation in me.  

There is a respirator design called PAPR (pronounces "PAP-er") where a small battery, motor and filter are combined into a single casing that clips to the user's belt.  This device filters the air and delivers it to a facemask or head-and-face mask through a tube.  The weight of the device is not carried on the head, but on the user's belt.

Above pictured is a researcher at the CDC working with influenza virus, which is spread when water droplets containing the virus contact nasal and oral mucosa.  His headgear is very lightweight.  The PAPR device is attached to his belt while a tube delivers air under positive pressure to his head and face.

Powered Air-Purifying Respirators (PAPRs) also come in industrial strength type of rigs with integral helmut / faceplates.  These cost about $1,000+.

One of the limitations of the PAPR is that it is ambient air that is drawn in and filtered.  So it would not be effective for removing toxic gasses.  This rig does not offer nearly the level of protection that a fireman's PPRBA does.  But for respiratory dropplets, a PAPR and light head and face shield would work well.

USAMRIID uses Racal suits to evacuate highly infectious patients.

"A commercial product known as the Racal suit — or Racal space suit — is a portable personal protective equipment consisting of a plastic suit and a PAPR fitted with HEPA filters that supply filtered air to a positive-pressure hood (also known as racal hood). Racal suits were used by the Aeromedical Isolation Team (AIT) to evacuate patients with highly infectious diseases for treatment.[1][2]"

I always thought that if I were to attempt to provide home medical care to others in my town during a big epidemic, I would need a PAPR unit.  For most epidemics (influenza, ebola, infectious diarrheas) most of the medical care is simple "support."  IV fluids are by far the most important element of support for a person who cannot eat, is vomiting and having profuse diarrhea.

A medical provider (paramedic, nurse, doctor) with IV start kits, fluids and tubing, and protective gear, could go house to house starting IVs on the patient's front porch, leaving them at home to be cared for by their family (who are probably already exposed), increasing survival rates during many types of pandemics.

This person is wearing a PAPR on her waist.

Here is a video by the Minnisota Dept of Health training nurses how to put on a PAPR between the 7:00 and 8:00 minute marks.

TechGuy's picture
TechGuy
Status: Gold Member (Offline)
Joined: Oct 13 2008
Posts: 453
PAPR

I bought the 3M Versaflo PAPR with the soft hood, extra battery & extra filters. So far I've only used it once when I was cutting a dry hay field and the dust was getting into my eyes even with safety glasses on. I don't like to use googles or a full face mask as it tends to fog up. The PAPR does not, but it can get hot if you use it during the summer months. I would recommend getting a white hood (not a black or dark colored hood since it will heat up more). I opted for the soft hood (see Pict above with girl in Yellow Suit) over the face mask since the hood will cover your entire head (dust and debre) can get in your hair and there is more space between the face glass and your face (less claustrophobic & fogging). Its also easier to store since its basically a bag except for the face glass sheild so it can fit into a small space.

The problem is that you cannot carry a PAPR with you everywhere. I don't like storing batteries in the car (ie too hot or too cold temperatures). I keep a dozen N95 masks in my car and a couple of N95 masks & a pair of safety glasses in my laptop bag that is usually near me at all times. I started carrying the N95 masks after 9/11 when I saw all that dust fall down and cover all the people fleeing.

I also keep a full roll of paper towels in my car or a bag of them in my carry on luggage. When ever I am traveling I use the paper towels when I use the bathroom or wash up. Those hand air driers are ineffective of removing germs. I also like to wash my face when I use the bathroom to also remove any germs. Using this method I have avoided getting sick while travelling. I also use the spent Paper towel to open the bathroom door to avoid getting my hands contaminated.

In my laptop bag (always close by to me) I also keep a small flashlight,  Several pairs of Nitrile gloves, NSAID (Advil), Handwarms (during winter months). Ear plugs, Cash & a multitool, a couple of granola bars, and some handwipes. Thus I have some basic supplies to get me out of a jam. All these items is no more than a pound & and I had no trouble going through an airport with these items.

 

 

nedyne's picture
nedyne
Status: Bronze Member (Offline)
Joined: Jan 14 2012
Posts: 73
Respirator?

Wow PAPRs are expensive. I have no trouble breathing through an N95 mask, but I was looking for something more protective than an N95 for pandemics, yet more affordable than a PAPR (under $100). 

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