As we have already seen, germs have partnered with human conquest, warfare and migration for as long as we have documented human history. Microbes have relied on a range of strategies to aid transmission to new hosts that would allow entry, nutrition, reproduction, and new opportunities for spread.
Human behavior itself – including greed, opportunism, and cruelty – have aided in the spread of disease, and often created waves of acute and chronic disease with lasting negative impact. The reality is that we share this planet with all living organisms, and their ecosystems have directly impacted our own.
In this final segment of our survey of epidemics around the world, we begin with one of the most famous episodes on American soil – the the H1N1 Bird Flu Epidemic of 1918. As historian John M. Barry noted in his New York Times best-selling book, “The Great Influenza: The Story of the Deadliest Pandemic in History,” that epidemic killed approximately 675, 000 Americans and more than 50 million worldwide at a time when population numbers were roughly 1/4 of what they are today.
Complicating our public response was our recent entry into WW I. As Barry noted, “We were at war. It was the first total war. It was the first time the government tried to fully control the public. The pandemic was known as Spanish Flu, but we know it did not start in Spain. It was called Spanish Flu because Spain was not at war, so there was a free press. Most of Europe had a censored press. The U.S. press was more open, but still the new Sedition Act of 1918 was passed. This was a law that made the Patriot Act look like it was written by the ACLU (American Civil Liberties Union)….In 1918, Departments of Public Health were often referred to as Departments of Public Assurance.”
Nations involved in the war were careful not to report that their troops were compromised by the illness. The first reports from Spain appeared on May 21, 1918. By the time reports appeared in the London Times on June 2nd under the banner, “The Spanish Epidemic,” the name had stuck.
But in reality, it appears the first cases appeared much closer to home, in March 4,1918. The first official case noted was in an Army cook, Albert Mitchell, at Camp Funston (now Fort Riley) in Kansas, though it had been reported in other parts of the state earlier. What is undisputed is that it spread like wildfire and was deadly. Within days, over 500 of the cook’s fellow soldier were ill with a respiratory infection, but most survived.
As soldiers shipped out overseas, they carried the infection with them. By late Spring, 3/4 of the French troops, 1/2 of the British, and close to a million German troops were infected. But the worst arrived in a second wave of infections that gained steam in the Fall of 1918. While the first wave resembled traditional flu, the second wave proved far more deadly. Between September and December, 1918, nearly 300,000 Americans had perished.
Most agree that this H1N1 virus had North American origins. It was moderately transmissible, with an infected person on average passing the infection along to 2 to 3 others, similar to modern day Covid. But spread was greatly enhanced by wartime movement of troops and crowded conditions. In the absence of a viral vaccine or modern antibiotics to combat secondary bacterial pneumonias, the course was rapid and acute. An unusual feature of the illness was that approximately 90% of the deaths occurred in people under 65, especially ages 20 to 40.
Preventive steps like isolation, mask-wearing, and quarantine were uneven at best. The largest problem was initial cover up of the crisis and miscommunication supported by President Wilson’s propaganda machine. Some quotes from authorities at the time: “Worry kills more people than the disease itself,” “Don’t get scared,” and “The so-called Spanish influenza is nothing more or less than old fashioned grippe.” One public health leader insisted, “This is ordinary influenza by another name.”
John Barry believed mortality varied from 15% to 53%. And unraveling of the very fabric of society seemed imminent. According to Barry:
“There was a lot of cognitive dissonance. People heard from authorities and newspapers that everything was going fine, but at the same time, bodies were piling up. Imagine your spouse lying dead in bed for six to eight days. There were coffin shortages. The dead were piled up where they died. There were police going around asking people to ‘bring out their dead.’ Panic was incipient. Even if there was war, the war was removed from us. The fear was so great that people were afraid to leave home or talk to one another. Everyone was holding their breath, almost afraid to breathe, for fear of getting sick. Army camps were shut down. People didn’t want to let soldiers return home. People were afraid to have any intimacy with their community and loved ones. Nobody would bring food in or come to visit.”
In advising the CDC in 2006, Barry had this takeaway message: “False reassurance is the worst thing you can do. Don’t withhold information, because people will think you know more. Tell the truth— don’t manage the truth. If you don’t know something, say why you don’t know, and say what you need to do to know. Drown people with the truth, rather than withhold it.”
In 2020, as Covid-19 gained steam, Barry was asked at the University of Rochester, to reflect on the similarities and differences between the 2018 virus and the modern counterpart that has appeared on our shores a century later. Here is what he had to say:
“They’re both animal viruses that jumped to humans. So, they’re novel for the given population. The mode of transmission is identical: primarily droplets, some airborne, maybe some fomite [transmission from contact with objects]—nobody knows how much.
Number three, they’re both primarily respiratory viruses.
Number four is less well known, and that is that the 1918 virus infected practically every organ, much like COVID-19. There were notable neurological impacts and cardiovascular events—they were very common. It’s been noted that even the testes can be affected. That was true in 1918 as well. That’s very unusual and certainly not the case for other influenza viruses.”
“It’s hard to say what’s most important, but I guess the most important one is a different target demographic. In 1918, roughly 95 percent of the excess mortality was people under 65. Of course, that’s the opposite with COVID.
And number two is duration. This virus moves much more slowly than influenza, whether it’s the incubation period, how long you shed virus, or how long you’re sick.
It has put vastly more stress on the economy because of the duration. We tried to interrupt transmission and save people’s lives, which I think was the right thing to do. But it certainly caused an increase in economic stress.
The most obvious difference is virulence—the rapidity of the virus’s spread and its severity. In 1918, it was many times more virulent.”
A final similarity, already becoming evident, is that it is hard to shake a virus if you give it enough time to mutate and adjust its transmissibility and lethality. There were 4 different waves of the original 1918 Flu, and their impact was very variable, one region to the next. For example, the fourth wave extending into 1920 witnessed a decline in the virus in many locations. But in New York City, 6,374 deaths occurred between December, 1919, and April, 1920, almost twice the number of deaths from the first wave in 1918.
But for the small native Alaskan town of Brevet Mission, Alaska, it was the second wave that struck with a vengeance between November 15 and 20, 1918. In this town, 72 of the 80 adults perished. The remaining few survivors buried their families, friends and neighbors in a mass grave. Their stories would not go untold. Researchers would follow the trail of DNA in1990’s as they brought the H1N1 virus back to life. More on that tale later. But for now, these Inupiak Natives were engulfed in the deadly process that caused U.S. life expectancy to decline by 12 years overnight. A loss in life expectancy was also a feature with Covid, though not as striking – 3 years on average.
As we noted last week, with the onset of WWII, FDR appointed Vannevar Bush to manage all science preparations. Part of that effort was directed at immunizations of all service people so that a disaster like the one ignited in Kansas in 1918 would not occur again. Included were Smallpox, Typhoid, Tetanus, Yellow Fever, and Influenza. By 2022, the list of mandatory vaccines for military had grown and included Anthrax,
Covid-19, Hepatitis A, Hepatits B, Influenza, MMR, Meningococcal, Pneumococcal, Polio, Rabies, Tetanus, Typhoid, and Varicella.
During this same period, FDR signaled the beginning of the end of an especially tragic infectious disease – Polio. The first cases were reported in 1894 in Rutland, Vermont. 18 died and 123 (mostly children) were paralyzed. When the war struck in 1918, the country was wheeling from 28,000 cases that year. Only three years later, Roosevelt would be stricken him
It was on August 9, 1921, after a brief swim in frigid water off of Campobello Island in Maine that the 39 year old New York lawyer with a bright political future, came back to the cabin he was sharing with, among others, his wife, Eleanor. By the next day, he had developed a fever and rapidly ascending lower extremity and facial paralysis. Alarmingly, this all was accompanied with significant pain, and the cessation of bowel and bladder function.
After a few days of missteps, and communications with experts at Brigham and Women’s Hospital in Boston, he was transferred to New York Presbyterian Hospital. There he was definitively diagnosed with polio and began a slow, but painful incomplete recovery. Along the way he endured breathing difficulties, blood clots, urinary sepsis, skin ulcers and more. Once discharged to his home in New York City, he was left to chart his future, permanently paralyzed from the waist down.
He was fitted with steel braces that locked at the knee, and determinedly built his upper body strength. In 1923, bought himself a houseboat, and a crew sailed him down to Florida where he fished and designed a pulley to allow him to be lowered into the water. Evaluations by his doctors at the time showed no improvement and a poor prognosis, which Roosevelt never accepted. As time went on, he traveled more and spent little time with his 6 children or wife. According to one historian, between 1925 and 1928 he was away from his New York home more than half the time, and Eleanor was present with him in that home for only 4 weeks.
He placed much of his hope for recovery on the healing waters and hydrotherapy offered in Warm Springs, Georgia. Here is where he mastered his torso swiveling “two-point-walk.” He liked the place so well that by April, 1926, he had bought it. And two years after that, having convinced all that he was “in recovery,” he successfully captured the first of two terms as New York’s governor, followed by his first of four terms as President.
Two years into his first term as President, in 1934, FDR hosted his first “Birthday Ball” and raised one million dollars for his Georgia Warm Springs Foundation – the site he returned to again and again for rehabilitation after contracting the debilitating disease.
He continued the yearly events and four years later in 1938, he broadened the effort creating the National Foundation for Infantile Paralysis (NFIP). To this mix, FDR added two additional resources – great management and celebrity support. Management came in the form of Basil O’Connor, attorney and close friend of the President. Their friendship predated FDR’s polio and included O’Connor serving as his legal adviser and for a brief period of time as his partner in the practice of law. He would serve loyally in that capacity for more than three decades.
O’Connor’s first order of business was to set up an organizational structure with reach across the country to support services and fundraising. Ultimately, 3100 chapters would be established and $233 million distributed in patient services for children with polio by 1955.
Much of that funding came from a unique idea first presented by radio personality and FDR supporter, Eddie Cantor. Singer, dancer and comedian, he went by the label “Apostle of Pep”, and matched energy level with FDR, stride for stride. At the time Cantor became involved in the Foundation, he had just completed a term as the president of the Screen Actors Guild. In that capacity, he was very familiar with a radio series and accompanying theater newsreel programs titled, “The March of Time”.
Narrated by radio pioneer Fred Smith, and funded by TIME magazine, the program was the first of its kind “dramatized news format” complete with sound effects and music. In January, 1938, Cantor went on his regular radio show and announced the “March of Dimes”, a take-off on the popular newsreel show name. He asked his viewers, young and old, to mail a dime to the President to help beat polio. His many celebrity friends chimed in, amplifying the name and the message, and the “March of Dimes” brand was born. Nearly 3 million dimes arrived at the White House with that first drive, raising 268,000 dollars in change.
Jonas Salk was recruited to the University of Pittsburg in 1947. In 1948, he received a grant from the National Foundation for Infantile Paralysis (NFIP) to identify the various types of polio. But Salk’s goals were much more expansive. He intended to develop the first successful vaccine for the disease and devoted the next seven years to that effort.
Fully funded by the NFIP at $7,500,000, and therefore requiring no need to be distracted by fund raising, Salk initiated a trial on 15,000 children in Allegheny County, Pennsylvania in 1953. The decision to stay close to home vastly simplified the logistics and avoided extra red tape. It didn’t hurt that he also tested himself, his wife and his children or that he achieved startling results on his first try out. Blood drawn from his subjects revealed antibody levels to polio that were 4 to 16 times the levels in non-treated children. These results were reported out in the Journal of the American Medical Association on March 25, 1953.
Following this announcement, which received worldwide attention, Salk took two additional steps that clearly demonstrated both his political and scientific prowess. First he went to Basil O’Connor at the NFIP and secured 100% funding for the largest scientific study that would ever be run in the US. In addition to securing that funding, he enlisted the vast marketing expertise and distribution system of the NFIP.
Secondly, rather than design the trials himself, at a time when scientific competitors were nipping at his heels, Salk enlisted his very popular and highly respected former mentor, Thomas Francis, to design and run the trials. Besides his scientific reputation, Francis had a distinguished record of public service having been the director of the Commission on Influenza for the Army Epidemiologic Board. By 1953, he was a renowned virologist and chair of the epidemiology department at the University of Michigan’s School of Public Health. Once Basil O’Connor with Salk chose Dr. Francis, they carefully created a firewall between themselves and the scientific trials.
Francis was fully aware of the deficiencies in the design. Did every parent clearly read the permission material? Clearly not. Was defining the trial’s purpose “to determine the effectiveness of a vaccine in preventing paralytic poliomyelitis” understating the trial’s experimental nature? What sufficed as a “valid parental signature”? Why were the terms “permission” and “human experiment” found nowhere on the consent form? Was Basil O’Connor’s letter on behalf of the NCIP that accompanied the parental materials and defined their child as having been “selected to take part in this great scientific test” overselling? And did he consciously underplay risk and deliberately transfer liability when he capitalized the words “THE VACCINE WILL BE GIVEN ONLY ON REQUEST OF THE PARENTS” in his letter?
Doctors across the nation in the Spring of 1954 received carefully wrapped parcels. They contained indistinguishable vials of the vaccine and placebo. These physician volunteers used the materials to inject 2nd graders, who received for their trouble a much sought-after button and card declaring them a “Polio Pioneer”. That was Basil’s idea, as it was to give all the children who participated, including the controls who received no injections, buttons as well. In his view, no one should feel left out of this national public effort to beat the enemy – Polio. This was, from a Public Health standpoint, all about solidarity.
The study remains controversial to this date with two arms – randomized and observed control. The former served the needs of scientists, while the later was felt necessary to maintain public support. In the randomized arm, 2nd graders either received the active vaccine or a placebo, and 1st and 3rd graders were left untreated and served as “controls.” In a second observed control model, all 2nd graders received the vaccine.
The end results were startling and have never been replicated since. Beginning April 26, 1954, within a year’s time, 1.8 million children in 15,000 schools in 44 states were recruited for the experiment. 300,000 health professional volunteers, including the majority of the physicians in the United States, participated without pay. 750,000 of the children – all 2nd graders form public and private schools – were part of a rigorous double blind study.
It was Dr. Francis who stood up on April 12, 1955 at 10:20 AM in Rackham Lecture Hall at the University of Michigan in Ann Arbor and declared in his characteristic direct style, “The vaccine works. It is safe, effective and potent.” The vaccine was arriving just in time. The year 1954 witnessed nearly 60,000 cases in the U.S., the highest ever recorded.
The Salk vaccine was an inactivated dead portion of the polio virus. Salk was opposed to using the customary vaccine methodology of running a virus multiple times through a laboratory animal to create a vaccine weakened or attenuated enough to not make a human sick.
Albert Sabin took a more standard approach, offering a live but attenuated oral vaccine. It had two things going for it – it worked better and lasted longer. that proved to be superior in administration, but also provided longer lasting immunity than the Salk vaccine. In 1962, the use of the Salk vaccine began to waiver as the Sabin vaccine came into general use in the U.S. after clinical trials in 1958 and 1059. By 1962 the Sabin vaccine was dominant. By 1963, Oral Polio Vaccination (OPV) was required for public school children, and effectively eradicated.
That is where the story ought to end. But this year, the virus began to be detected once again in analysis of wastewater from New York City sewage plants. The flash points for this new reality turned out to Hasidic Jewish communities, who oppose vaccination, in Brooklyn and Rockland County, NY. This is a graphic example that the threat of infectious disease is never completely gone, a lesson we’ve been forced to relearn, again and again.
The three decades following the Allied victory in World War II were marked by scientific hubris. Vannevar Bush’s effort as FDR’s “Scientist-in-Chief” had been remarkably successful – including a massive expansion of vaccines that were mandatory for all in the military. The errors of 1918 in Kansas were not to be repeated. The infectious diseases themselves seemed stalled, static, relatively benign and part of our historic past. General George Marshall declared confidently in 1948, “We now have the means to eradicate infectious disease.”
Plague had yielded to sanitary cordons, isolation and quarantine. Water and sewer management, plus pasteurization, had neutralized the threat of cholera. Vaccines were increasingly required for school entry. DDT, paired with quinine, had defanged, if not obliterated, malaria. In 1955, Rockefeller Foundation scientist Paul Russell published “Mastery of Malaria” recommending global DDT spraying campaigns – halted only by the dogged work and advocacy of Rachel Carson.
Johns Hopkins scientist, Aidan Cockburn, caught the mode of the day in 1963, when he wrote, “With science progressing so rapidly, such an endpoint (of infectious diseases) is almost inevitable. Six years later, Surgeon General William H. Stewart, in encouraging a singular focus on chronic disease, declared with complete confidence that it was “time to close the book on infectious diseases.”
Those who did not agree tended to be outliers. One such individual was scientist Johan Hultin. In 1951, he was a medical student from Sweden interested in microbiology and pathology who was spending 6 months at the University of Iowa. He became intrigued by the Flu Epidemic of 1918, and more specifically its causative agent. Iowa microbiologist William Hale that identification would required well-preserved tissue from a victim, still frozen, and perhaps buried in permafrost.
This was not beyond Hutlin’s imagination since he had accompanied paleontologists the prior summer on an unsuccessful dig in Alaska the year before. With a $10,000 grant from Iowa, he headed north in June, 1951. Eventually he settled on the small town of Brevig Mission, where local records revealed the mass burial of 72 of the 80 adults in the village of Inupiat natives in 1918, victims of influenza. Gaining the trust of surviving elders of the native Inuit tribe, he uncovered the grave, and entered frozen ground 7 feet below, with a child’s body with well preserved lung tissue. Without much thought for the risk involved, he brought the specimen back to Iowa and tried growing it in eggs, and in live laboratory animals, but failed.
He went on to study pathology at the Mayo Clinic, and had a successful career, but never forgot the people of Brevet. At the age of 70, while on vacation in Costa Rica, he happened to read a paper published in Science by scientist Jeffery K. Taubenberger describing finding snippets of the 1918 virus in preserved lung tissue removed at autopsy in 1918 and saved in wrapped paraffin. That led to a meeting, and a return visit to Brevet, which we’ll return to shortly.
The end of our nation’s scientific hubris arrived on June 5, 19821, in the form of a carefully worded announcement in the government’s “Morbidity and Mortality report (MMWR). The headline on page 1 was not particularly alarming. Pneumocystis Pneumonia – Los Angeles. Buried inside the short article however was this piece that set off alarms in San Francisco’s gay community: “Pneumocystis pneumonia in the United States is almost exclusively limited to severely immuno-suppressed patients. The occurrence of Pneumocystosis in these 5 previously healthy individuals without a clinically apparent underlying immunodeficiency is unusual. The fact that these patients were all homosexuals suggests an association between some aspect of a homosexual lifestyle or disease acquired through sexual contact and Pneumocystis pneumonia in this population.” What lay ahead was an epic clash between religion and science.
On the day after Ronald Reagan’s election, Christian conservative Jerry Falwell was euphoric. As he said, “I knew that we would have some impact on the national elections, but I had no idea that it would be this great.” One other big personality who saw, in Reagan’s win, a win of his own was C. Everett (Chick) Koop. Carl Anderson, a Catholic aide to North Carolina Senator Jesse Helms, had informally approached him that fall to explore in earnest his willingness to accept the nomination as Surgeon General of the United States.
For Chick, the timing was perfect. At 64 1/2, he saw his days in the operating theatre at Children’s Hospital in Philadelphia as numbered. He was filled with a sense of mission that energized him, and his wife, Betty, was encouraging him to pursue the new role. In his customary fashion, Chick did his homework, gauging his supporters and his opponents. Among the former, in addition to Jesse Helms and Strom Thurmond, there was the conservative Catholic Henry Hyde of Illinois. Regrettably on the negative side of the ledger sat the American Medical Association, which saw him as unpredictable and were already on record as supporting University of Texas vice chancellor of Health Affairs, Edward Brandt Jr.
The opposition of the AMA should have been an early warning signal. For the dignified surgeon and conservative Presbyterian, who was used to professional adulation, and believed that he had led a conscience driven, moral and upstanding life, in the service of his fellow Americans, the APHA move was a slap in the face. But that was nothing compared to what he read on the editorial page of the New York Times when he opened his paper on April 9, 1981. There, in black and white, was the lead editorial with a blaring title – “Dr. Unqualified”. In the editorial, they acknowledged in the first line that he had a “fine reputation as a pediatric surgeon” but found him “not deserving” of the role of Surgeon General. The charge that he had no “significant experience in the field of public health” wasn’t a big surprise, especially since the APHA had torched him. But the attack that followed, cued up by the supposition that his “attractiveness to the Administration must lie elsewhere” had to bring a grimace to his stately face.
Answering their own query, the editors said, “That ‘elsewhere’ may be his anti-abortion crusade. Two years earlier, he and Francis Schaefer had toured 20 cities with a film whose message was that abortion led inexorably to euthanasia for the elderly. And he has described amniocentesis, a procedure used to detect congenital disorders like Down’s syndrome and Tay-Sachs disease in fetuses, as ‘a search-and destroy mission.’”
Pending approval, Schweiker put Koop on the payroll as his assistant. The months dragged on, and Koop, encouraged to stay under the radar screen, focused on establishing as many relationships as possible. The people he met were surprised, as they had always been throughout his life. The severe physical package did not reflect the accessible and generous individual within.
In October, 1981, while testifying before Congress, he surprised his audience when he stated clearly, “It is not my intent to use any government post as a pulpit for theology”. Apparently, his Christian conservative backers thought this was simply a matter of political sleight of hand. But for the Democratic leaders, like Henry Waxman and Ted Kennedy, this was a turning point. In November, the Senate confirmed him with a vote of 68 to 24, and on January 21, 1982, more than a year after the battle had engaged, C. Everett Koop was sworn in as the 13th Surgeon General of the United States.
On April 13, 1982, nine months after the initial alert, Senator Henry Waxman held the first Congressional hearings on the growing epidemic. The CDC testified that tens of thousands were likely already infected. On September 24, 1982, the condition would for the first time carry the label, AIDS – acquired immune deficiency syndrome.
Koop’s focus at the time, along with the vast majority of public health leaders across the nation, was not on a new emerging infectious disease, but rather on the nation’s chronic disease burden, especially cardiovascular disease and cancer being fed by the post-war explosion of tobacco use. He had already surmised that the power of his position lie in communications and advocacy, whether from the podium, before Congress or in front of the television cameras. He also understood very well, from his adventures with Francis Schaefer, that his image, voice and stature were memorable.
But in the most pressing public health challenge of the day, HIV/AIDS, the department was AWOL. HHS Secretary Margaret Heckler, probably at the insistence of Reagan’s domestic policy adviser and “family values” enforcer, Gary Bauer, had assigned themselves the duty of addressing all questions on HIV/AIDS. It was explicitly off-limits to Koop.
Not surprisingly, the situation deteriorated rapidly. Heckler at one point suggested that AIDS was Reagan’s “number one priority” even though he had never uttered the words HIV/AIDS in public. She also told the public to expect a curative vaccine in two years. That was 1984. As more and more people died – now not only gays, but also heterosexuals, hemophiliacs, drug users, newborns of infected mothers – Reagan’s silence became deafening. To relieve the pressure, in 1986, the President finally directed Koop to coordinate a report on AIDS for the American public.
In October, 1986, Reagan first uttered the word, AIDS. By then, over 16,000 Americans were already dead. Inside his Administration, Reagan gave voice earlier to people like Bill Bennett who discouraged providing AIDS information in schools and Gary Bauer, who Koop said, was “my nemesis in Washington because he kept me from the President.” And Bauer wasn’t the only one. Jerry Falwell declared the disease “the wrath of God upon homosexuals”. Pat Buchanan cruelly labeled the disease “nature’s revenge on gay men”. And William F. Buckley suggested, in a New York Times article on March 18, 1986, that HIV-positive gay men should have the information forcibly tattooed on their buttocks.
Reagan’s conversion was indirect. Elizabeth Taylor wrote he and Nancy a letter on April 10, 1987, that began, “On Sunday evening, May 31st, at 6:00 P.M., at Potomac on the River, the American Foundation for AIDS Research will host a dinner to help raise the research funds that are so desperately needed to help stop the ‘AIDS epidemic’ that threatens us all. Also, during the dinner, U.S. Surgeon General C. Everett Koop, will be honored for his leadership in educating the public on the AIDS issue. I am writing from my heart to ask if you both would attend the dinner and if you, Mr. President, would give the keynote speech.” The actress felt the time had come, not only because of their friend Rock Hudson’s publicized death, but also because the latest federal budget included an 11% cut in AIDS spending compared to the prior year.
On that evening, May 31, 1987, he delivered his first major address on the topic. It was six years late. 21, 000 Americans were now dead, and 36,000 more lived with a diagnosis of the disease. His prior actions could not be blamed on ignorance or lack of exposure. Koop had done his best to keep the President informed. Nor is it possible to simply say that his bias against gays was historic or “principled”. In fact, his defeat of Jimmy Carter in 1980 was achieved with active gay support in California in return for his opposition to the Jerry Falwell and Anita Bryant led antigay measures that went down in defeat in California in 1978 with his help.
From 1983 to 1985, Koop was excluded from the Executive Task Force on AIDS. Heckler had now been burned twice and was more than willing to push the increasingly popular Koop out front. The public was becoming more and more fearful, as the numbers of dead and infected rapidly rose. Politicians, and some physicians, were calling for mandatory testing, once a test had been developed to detect the virus in blood in 1985. This followed heavily publicized cases of death from HIV tainted blood in hemophiliacs, and fears that the entire US blood supply might be contaminated.
If Chick and Fauci needed a climactic turning point, a moment that linked them together, it perhaps came on December 17,1984, when a young hemophiliac from Kokomo, Indiana, undergoing a partial lung removal for severe consolidated pneumonia, was diagnosed with HIV/AIDS. His name was Ryan White. He was 14 years old at the time. He became infected while receiving an infusion of a blood derivative, Factor VIII, for his hemophilia. When he was cleared to return to school, 50 teachers and over a third of the parents of students from his school signed a petition asking that his attendance be barred. Koop clearly understood that continued inaction on his part would be unacceptable. This was what could happen in the absence of his leadership and the provision of proper health education. For Ryan White, after the state’s health commissioner and the New England Journal of Medicine reinforced that the child’s disease could not be spread by casual contact, he was readmitted to school in April, 1985. He would die 5 years later, and legislation, in his name, would open up much needed federal funding to care for those affected by the disease.
When President Reagan, feeling the pressure, finally did direct Chick to create a report, he was more than prepared to respond. The Administration’s focus was on testing, detection and isolation. Koop would deal with those issues, but he already knew that his major emphasis had to be on prevention. He interviewed AIDS activists, representatives from the medical and hospital associations, Christian fundamentalists, and politicians from both sides of the aisle.
Few knew fully what he was up to. One exception was his colleague and personal physician at the National Institute of Health, Infectious Disease specialist, Tony Fauci, who headed up the AIDS Research effort for the NIH. Chick learned everything he could about the virus, its’ behavior and transmission from Fauci, which he intended to share with the public in the future. Fauci also was the first to actively include the vocal AIDS activists in the government’s scientific advisory boards in their effort to combat the disease. At first the target of their anger and frustration, as more and more died in the face of a clearly disinterested government and hysterical public, Fauci subsequently earned the praise and admiration of leaders of the AIDS activist community.
Koop would consult with Fauci, day by day, as he formulated his drafts in secret. Fauci would later note, “He would come home from hearings downtown as things started to accelerate with HIV. As he was walking home, he had to pass my office. Around 7:30 at night, he would come knock at my door. He would say this thing about AIDS is very troubling, and I want to make the right impression on public awareness. He got it in his mind that we as the federal government need to be explicit about this — oral and anal sex, commercial sex. He was hell-bent on doing it. When it came out, it shocked a lot of people because of its explicitness.”
The entire effort was quick, comprehensive and confidential. In October of 1986, he carefully walked the Administration through a draft tailored for approval, collecting all print copies as participants left the room, to make it more difficult for his detractors to organize a blocking effort, now or in the future. On October 22, 1986, the report was officially released, and challenged parents and schools to discuss AIDS, promote public education, and employ condoms for prevention. The report drew immediate criticism from the Conservative Right, but nothing compared to the furor that arose nineteen months later.
In the period following the initial report’s release, Koop quietly employed the Public Relations firm, Ogilvy and Mather, to make certain he had the messaging, language and imaging right. He then created an 8 page pamphlet for mail distribution, after raising adequate funding on the side, from various branches of government, to support the mass mailing costs of delivering 107 million copies of the publication to every household in America.
In the forward he wrote, “At the beginning of the AIDS epidemic, many Americans had little sympathy for people with AIDS. The feeling was that somehow people from certain groups ‘deserved’ their illness. Let us put those feelings behind us. We are fighting a disease, not people…The country must face this epidemic as a unified society. We must prevent the spread of AIDS while at the same time preserving our humanity and intimacy.”
His inside message was a call to action. His dramatic image was attached to the title: “A Message From The Surgeon General”.
Understanding AIDS was not an innocent read. It was frank and factual, covering anal and vaginal intercourse, injectable drug transmission, and condoms for starters. It promoted sex education beginning in elementary school and pierced the current messaging of the most popular Christian televangelists of the day with this comment: “Who you are has nothing to do with whether you are in danger of being infected with the AIDS virus. What matters is what you do.”
The messaging had been tested and found to be effective. The mobilization effort and quiet execution would have impressed the CIA. The huge 1988 print run required government printing press activities 24 hours a day for several weeks. Delivering the load for mailing utilized 38 boxcars. And approval for the mailing skirted normal procedure. When the eight page pamphlets began to arrive, the phones in the Senate offices of conservatives like Jess Helms rang off the hooks. Falwell and Robertson, and their like, were apoplectic. Attempts to halt it were futile. The mass mailing had been completed in bulk. There was no going back.
The medical community applauded loudly, as did the Press and the majority of the public. When his original Baptist patrons, and their captive Senators went after him, he took no prisoners. “I’m the nation’s doctor, not the nation’s chaplain”, he said.
When Chick Koop died at age 96, on February 25, 2013, Tony Fauci remembered him saying of the couple years earlier, ‘Tony, you do the science, I’ll do the education for the public.’”
The experience with HIV/AIDS was humbling for the NIH and America’s scientists. They were forced to acknowledge that they were now on the defense. This reality was publicly acknowledged in a formal Institute of Medicine (IOM) report in 1992 titled, “Emerging and Reemerging Infections.” In its summary, there was a shocking admission about humans balance of power with microbes, “…they outnumber us a bullion-fold, and nutate a billion times more quickly.”
By 1996, there were full-blown Congressional hearings. On May 31, 1996, Dr. Michael Osterholm, the Minnesota epidemiologist respected by all, testified, “I am here to bring you the sobering and unfortunate news that our ability to detect and monitor infectious disease threats to health in this country is in serious jeopardy…For 12 of the States or territories, there is no one who is responsible for food or water-borne surveillance. You could sink the Titanic in their back yard and they would not know they had water.”
That same year, Nobel Laureate, Joshua Lederberg, MD, stated, “Our fight with microbes is far from over…odds are tipped in their favor…pitted against microbial genes, we humans mainly have wits.” He was stating this as Ebola was emerging as a threat its Africa, and eventually to the U.S. Six years later, another avian virus from China would literally shut down Canada’s economy for months. A year later, in 2003, President George W. Bush would create the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). Infectious diseases were now on everyone’s radar screen.
Scientists at the NIH struggled with the challenge Dr. Lederberg had raised seven years earlier, how best to “outwit” microbes with a superior evolutionary advantage. The answer they felt lay hidden within the viruses genetic code, and their constant responsive mutating and invasive structure. Which takes us back to Johan Hultin and the Brevid Mission, Alaska 1918 victims.
When we left off, the now aging, and partially retired scientist, who had recovered samples from victims of 1918 back in 1957, but had failed to isolate the causative agent and bring it back to life, was reaching out to a government scientist. The 71 year old Hultin, after reading a publication by Dr. Jeffery Taubenberg, and his coworker Anne Reid reporting they they had recovered lung tissue with embedded viruses from 1918 victims, reached out and suggested a return visit to Alaska.
Within a few months they were onsite, and once again were permitted by surviving Inupiaq village elders to unearth the ancient burial sites for a second time. As Inupiat leader and elder Rita Oleana said to Hutline on his second visit to their village,, “My grandmother said you treated the grave with respect.” Seven feet under, embedded in permafrost they uncovered a seven year old girl, and successfully retrieved tissue samples. These were packed in dry ice and delivered to the NIH campus. At the recovered grave site, they left a cross bearing all of the victims name with the message, “The following 72 Inupiat Eskimos are interred in this common grave. Pray, honor, and remember these villagers who lost their lives during the short span of five days, in the influenza pandemic. November 15-20, 1918.”
They now faced a monumental and controversial decision point – Should they try to bring the 1918 virus back to life?
After vigorous debate, weighing any potential human benefits that might be derived from understanding the virus’s secrets (and overcoming them in the future) versus the risk of injuring investigators and unleashing a modern epidemic, they decided to proceed. Part of that calculation involved their confidence in scientist Terrence Tumphey who ran their high security Level 3 lab on the NIH campus. Their faith in him paid off when, in 2005, he safely and securely brough the original 1918 virus back to life. By recreating the virus, scientists were able to study it structure, identify what made it so infective, probe for weaknesses, and consider what type of mutations might add to its danger to humans.
The research, title “Gain-of-Function” research was clearly high risk/ high reward. What they learned was that “the viruses rapid multiplication created a virus load that was 50 times as great as every day respiratory viruses and almost exclusively targeted lung tissues. These deadly attributes were the result of eight separate but contributory unique mutations of the virus genetic structure.”
Not all scientists approved. One consensus group stated, “Accident risks with newly created ‘potential pandemic pathogens’ raise grave new concerns. Laboratory creation of highly transmissible, novel strains of dangerous viruses…poses substantially increased risks. An accidental infection in such a setting could trigger outbreaks that would be difficult or impossible to control.”
To their credit, the government was largely transparent. Its’ own 2019 report, “The Deadliest Flu: The Complete Story of the Discovery and Reconstruction of the 1918 Pandemic Virus,” laid out the competing interests. Were there risks? From the CDC Report months before Covid-19 erupted: “Many experts think so. One virus in particular has garnered international attention and concern: the avian influenza virus from China.”
And these prophetic comments: “While all of these plans, resources, products and improvements show that significant progress has been made since 1918, gaps remain, and a severe pandemic could still be devastating to populations globally. In 1918, the world population was 1.8 billion people. One hundred years later, the world population has grown to 7.6 billion people in 2018.
“As human populations have risen, so have swine and poultry populations as a means to feed them. This expanded number of hosts provides increased opportunities for novel influenza viruses from birds and pigs to spread, evolve and infect people. Global movement of people and goods also has increased, allowing the latest disease threat to be an international plane flight away.
“Due to the mobility and expansion of human populations, even once exotic pathogens, like Ebola, which previously affected only people living in remote villages of the African jungle, now have managed to find their way into urban areas, causing large outbreaks.”
“If a severe pandemic, such as occurred in 1918 happened today, it would still likely overwhelm health care infrastructure, both in the United States and across the world. Hospitals and doctors’ offices would struggle to meet demand from the number of patients requiring care. Such an event would require significant increases in the manufacture, distribution and supply of medications, products and life-saving medical equipment, such as mechanical ventilators. Businesses and schools would struggle to function, and even basic services like trash pickup and waste removal could be impacted.”
Of course, the rest is history, though the origins of the Covid-19 will likely never be traced to a laboratory leak in which U.S. and Chinese scientists were complicit. As veteran Science reporter Nicholas Wade deciphered on May 14, 2021 in a classic article in Science – The Wire, “For 20 years, mostly beneath the public’s attention, they had been playing a dangerous game. In their laboratories they routinely created viruses more dangerous than those that exist in nature. They argued they could do so safely, and that by getting ahead of nature they could predict and prevent natural ‘spillovers,’ the cross-over of viruses from an animal host to people.”
At the core of Wade’s suspicions was the transfer of government funding to a shadowy New York City based organization called The EcoHealth Alliance. Wade had uncovered that the Chinese virologist at the epicenter of Covid’s breakout was a woman scientist named Shi Zhengli, who had trained in 2015 with well known virologist, Ralph Baric, at the University of North Carolina in lab techniques to create recombinant “chimeric viruses.” In 2018, she returned to Wuhan, China, and with Chinese endorsement to establish a center for viral experimentation.
The EcoHealth Alliance’s connection to Wuhan, and its director Peter Daszak’s connection to Shi Zhengli was somewhat insulated. Zhengli and Baric had teamed up in November, 2015 to manipulate the crucial spike protein of the SARS1 virus creating “chimera” – possessing genetic material from two different viral strains. At the time, other scientists were sounding alarms including Pasteur Institute’s Simon Wain-Hobson who wrote “If the virus escaped, nobody could predict the trajectory.”
The risky “gain-of-function” studies, were justified as super-secure, safe, predictive, and preventive. Shi returned to her labs in 2018 and 2019 with grant funding from the NIH’s National Institute of Allergy and Infectious Disease, shunted through Dayak’s intermediary organization to avoid, some believe, transparency and controversy.
Nicholas Wade read the grant proposal and somewhat alarmingly concluded that Shi was creating chimeric viruses with a range of human infectivity as measured in genetically altered “humanized” mice. In essence, she was assisting the virus in discovering “the best combination of coronavirus backbone and spike protein for infecting human cells.”
When you see pictures of scientists in space suits clumsily attempting to complete experiments, that is maximum safety – BSL4. As it turns out, Shi’s experiments on “gain-of-function” were conducted initially two rungs down the safety ladder, at BSL2, the safety level equivalent to a dentist’s office.
On January 15, 2021, the State Department released this statement, “The U.S. government has reason to believe that several researchers inside the WIV became sick in autumn 2019, before the first identified case of the outbreak, with symptoms consistent with both COVID-19 and common seasonal illnesses.”
This drew a sharp response from the established scientific community. Their coordinator-in-chief was one Peter Daszak, chartered power broker within the U.S. Medical Industrial Complex and president of New York based EcoHealth Alliance which was a major funder of Shi Zhengli’s work in Wuhan.
Daszak is known for adopting militarized terms in the battle against global infectious diseases. In 2020 he wrote in the New York Times, “Pandemics are like terrorist attacks: We know roughly where they originate and what’s responsible for them, but we don’t know exactly when the next one will happen. They need to be handled the same way — by identifying all possible sources and dismantling those before the next pandemic strikes.”
Daszak’s argument that risks involved in Shi Zhengli’s Wuhan bat virus research were justified as defensive and preventive was convincing enough to the NIH and the Department of Defense that his EcoHealth Alliance was funded from 2013 to 2020 (contracts, grants, subgrants) to the tune of well over $100 million – $39 million from Pentagon /DOD funds, $65 million from USAID/State Dept., and $20 million from HHS/NIH/CDC.
As Nicholas Wade’s investigation laid out in detail, while absolute proof remains to be uncovered, the overwhelming and rising mountain of evidence points to human error supported on a national scale. As Wade sees it, “The US government shares a strange common interest with the Chinese authorities: neither is keen on drawing attention to the fact that Dr. Shi’s coronavirus work was funded by the US National Institutes of Health.”
The NIH’s Tony Fauci stated, “We need to keep an open mind.” This apparently extends in both directions. His National Institute of Allergy and Infectious Disease, as recently as August, 2020, awarded $82 million to establish the Centers for Research in Emerging Infectious Diseases to ten principal investigators. Peter Daszak is #3 on the list.
On May 26, 2021, Francis Collins, head of the NIH, which funded in part Zhengli’s risky bat virus research (more on that in a moment), admitted to Congressional investigators that “we cannot exclude the possibility of some kind of a lab accident.”
It’s now well established that three Wuhan virology scientists were hospitalized in the Fall of 2019 with Covid. But the initial report from the Wuhan Municipal Health Commission, China, of this cluster of cases of pneumonia was only released on the last day of 2019.
It took only 50 more days for the tight knit group of global research virologists to get their act together and pen a Lancet editorial in which they stated “We stand together to strongly condemn conspiracy theories suggesting that COVID-19 does not have a natural origin,” and that they “overwhelmingly conclude that this coronavirus originated in wildlife.”
And all of this occurred as a mentally compromised President offered his own homegrown solutions after denying the pandemic’s significance for months. As with the 1918 Flu epidemic, Covid now is entering its 4th wave, more than 1 million Americans and over 6 million worldwide have perished, and we’re still having difficulty keeping pace with the microbes mutations.
So it’s fair to ask, where do we as humans now stand when it comes to managing epidemics? It is useful to begin with the fact that all microbes are not created equal in terms of their human threat. Three elements must always be considered: receptivity, transmissibility, and virulence.
Receptivity is multi-factorial. Maximizing receptivity requires microbe exposure to dense populations, frail and weakened, and without prior exposure to the infectious agent. When the conditions are all aligned, the organism has the opportunity to be transmitted from one human to another either directly or through an intermediary host. An agents transmissibility is often reflected in a reproduction number referred to otherwise as the RO or R naught. This reflects how many people each sick person will infect on average. A partial list looks like this: Influenza 1.5, Ebola 2.0, Covid and 1918 Flu 2.5, SARS 3.5, Mumps 4.5, Rubella 6.0, Smallpox 6.0, Measles 16.0.
Finally there is virulence. That is, what is the likelihood (expressed as a percent of total cases) that you will die from the infection. This is formally referred to as the Confirmed Fatality Rate (CFR). Here’s an abbreviated list: Covid 2.1%, 1918 Flu 2.5%, SARS 11%, Typhoid 10%, Malaria .3%, Dengue Fever 26%, HIV/AIDS 80%, Influenza .1%, Ebola 90%, Plague 60%. Covid has now overtaken the 1918 Flu as the deadliest in American history.
As our four sessions has well-illustrated, much of our vulnerability as a human species to epidemics is a function of our own human behaviors. The details and particulars of each tragedy are specific and have varied through the century, as has our understanding of the science, and our capacity, and willingness to launch a timely response to a crisis. Our microbial foes, as they have battled our human defenses have changed as well, evolving at breakneck speed, almost in real time. We share a common ecology, and more often than not, threaten each other’s existence.
Our vulnerabilities in modern times have shifted somewhat. How science is greatly advanced compared to the early days of the Plague. Humans in general are better nourished, educated, safer, and generally more secure. This is reflected in expanding lifespan over the past century. But in many ways, we are more vulnerable then ever.
High speed travel, global warming, changing migratory bird patterns, warfare, human dislocation and mass migration, gun violence, tribalism, racism, inequitable health care systems, mental health crises and seriously flawed national leadership all contributed to delayed and inadequate disease prevention and epidemic disaster responsiveness.
As we stated in slide one of this four part series, “epidemics are social, political, philosophical, medical, and above all ecological.” So it is useful to close with this one final, and distinctly modern case study.
A paper eight years ago, published in Nature, was titled “Study revives bird origin for 1918 flu pandemic.” The study, which analyzed more than 80,000 gene sequences from flu viruses from humans., birds, horses, pigs, and bats, concluded the 1918 pandemic disaster “probably sprang from North American domestic and wild birds, not from the mixing of human and swine viruses.”
When Tippi Hedren and Rod Taylor headed indoors at Bodega Bay, California in a high-speed attempted escape from sudden violent bird attacks in the Alfred Hitchcock 1963 natural horror-thriller film, The Birds, it was beaks not bugs they were trying to avoid. But sixty years later, we may all soon find ourselves nodding in agreement with the Library of Congress which declared Hitchcock’s work to be “culturally, historically, and aesthetically significant.” Tourists on the national mall this year would agree. They discovered a dozen dead mallard ducklings in the national Reflecting Pool. Vets quickly determined the cause – avian flu virus.
Last month’s Nature publication, written by science journalist Brittney J. Miller, titled “Why unprecedented bird flu outbreaks sweeping the world are concerning scientists,” raised the alarm. As she wrote “Mass infections in wild birds pose a significant risk to vulnerable species, are hard to contain and increase the opportunity for the virus to spill over into people.”
In the past 9 months, an H5N1 bird flu strain has ignited 3,000 outbreaks in domestic poultry populations across the globe – from Europe, Asia, Africa, and North America. Local governments have limited the damage by destroying (culling) over 77 million birds. But these chickens and turkeys don’t fly commercial, so how did their virus spread?
The answer lies in the dead bodies of another 400,000 wild birds, mostly water fowl, involved in another 2,600 outbreaks in 2022. So far, the virus doesn’t seem to like humans much. Only two human cases (one in the U.K. and another in the U.S.) have been flagged. But spillover, say experts, is inevitable with spread at this rate. A WHO representative says, “These viruses are like ticking time bombs. Occasional infections are not an issue – it’s the gradual gaining of function of these viruses” that’s makes everyone nervous.
Since 1996, wild birds have been in the cross-hairs. Back then, a pathogenic H5N1 bird flu appeared in geese in Asia. Within 5 years, it was all over Europe and Africa. Five years later, widespread mass deaths of wild birds appeared tracked back to the original geese. Within another 10 years, a worrying trend evolved. A strain throughout North America appeared that infected a range of wild birds but didn’t always kill them. For example, mallard ducks were routinely infected, but only 10% died. While good for the ducks, their survival fueled continued spread and reengineering through mutation of the virus.
As you might imagine, it’s not as easy to track and monitor wild birds as well as cooped up chickens. Nor is killing them in masse once infected a reasonable, or achievable option. From the wild bird’s perspective, these are not the best of times. If you are a ruddy turnstone or a resident duck on the Delaware Bay, things are heating up in more ways than one. Global warming is affecting the timing of horseshoe crab spawning season at the Delaware Bay. The northern Arctic migration (with a stopover at the Delaware Bay) of the ruddy turnstone (which feeds on the crab) has been prolonged as a result.
Many of these birds are bird flu carriers. The longer they hang around, the more they infect the local water fowl residents – especially, ducks, swans, geese, shorebirds, and waders. On top of this, when the ruddy turnstone and other migrators reach the Arctic, they are staying longer thanks to moderating temperatures and ice melting. Scientists have concluded that “these conditions support maximal transmissions (of viruses) across wild water birds.”
Climate change not only leads to northward shifts, but expanded species diversity, accompanied by shorter migratory routes. Both spell greater mixing and exchange of viruses across avian species. Spring migrations are now taking place earlier, with age classes, species and flyways significantly altered. Extreme climatic events, more common in an age of “global weirding” of weather, are also more common. For example, a cold clip near the Caspian Sea in 2006 triggered a mass exodus of swan, which unleashed an H5N1 viral outbreak in domestic birds across Western Europe.
What ecologists are saying is that “A1 viruses have co-evolved with migratory waterfowl over millions of years and have survived and withstood many eras of climatic turbulence… An increase in the proportion and number of birds over-wintering in the subarctic areas may result in very high densities of birds competing for the limited feed resources available. This could potentially enhance interspecies virus transmission, involve a larger spectrum of avian host species or alter the virus transmissibility, both to wild birds and domestic poultry.”
As more and more Canadian geese set up permanent domicile in the grassy wonderlands of suburban America, they and their wild avian friends are increasingly settled in, crowding together in a new world, permanently residing in intimate contact with humans. The shrill alarms set off by environmental scientists have now been joined and reinforced by an increasingly alarmed global infectious disease community. And that was before the report two months ago, on September 7, 2022, that an H5N1 virus that has been devastating bird populations around the globe this year was detected in the necropsy of a dolphin in Florida and in a poppies in Sweden. This is the first time a bird flu has been detected in an ocean crossing cetaceans.
So what lessons have we learned over the past four weeks?
- Epidemics, as historians have emphasized are “social, political, philosophical, medical, and above all ecological events.”
- Competing and complimentary species cycles in pursuit of nutrition and reproduction maintain, or distort, ecological balance.
- Populations initially respond to epidemics with fear and flight. Scapegoating and societal turmoil are common features. Diseases disadvantages the poor, the weak, and those without immunity or prior exposure.
- Epidemics often travel side by side with warfare in transmitting and carrying microbes, and exposing vulnerable populations. Historically, epidemics have repeatedly played a role in determining the ultimate outcomes of warfare and conflict.
- Throughout history, scientific advances have enabled (through travel , congregation, and entry into virgin territory) epidemics, and also provided the knowledge and tools to combat epidemics.
- Domestication and sharing of animals has enhanced the introduction of microbes to populations vulnerable to epidemic disease.
- Disease, rather than aggression, has been the major factor in native cultures and decimating native populations in the Americas.
- Slavery was largely a response to workforce demands created by the epidemic eradication of native populations intended to serve as indentured servants on large agricultural plantations that raised and exported highly lucrative products into Old World markets.
- Epidemics often result in unintended consequences. For example, Yellow Fever and the defeat of the French in Saint-Domingue led to Napoleon’s divestment of the Louisiana Territory. Struggles to control and explain the Yellow Fever outbreak in Philadelphia in 1793 helped define the emergence of two very different branches of American Medicine over the next century.
- Scientists defining “germ theory” and social engineers leading the “sanitary movement” reinforced each other’s efforts to lessen urban centers vulnerability to epidemics.
- Immunization has a long history and has been controversial. As enlightened public policy, it has saved many lives. It can, as illustrated by the Eugenics Movement, create uncomfortable legal precedents and unintended consequences.
- The U.S. scientific community prematurely declared victory over communicable diseases.
- In the wake of HIV/AIDS, some scientific leaders actively warned of ongoing population wide vulnerabilities beginning in 1992.
- Genetic reverse engineering technologies empowering “gain-of-function” led to Consensus Statements in 2014 of potential disastrous consequences, and epidemics that would be difficult to control.
- The U.S, Health Care System in leadership, strategic operation, mitigation, and delivery of acute services failed on a large scale when confronted with the Covid-19 pandemic.