Dark Winter: An insider’s guide to pandemics and biosecurity

Preface

Corona Dawn

ON NEW YEAR’S DAY 2020, I WATCHED MY SON devouring his bacon and eggs at the Qantas lounge, while my daughter was immersed in her iPhone. I had been planning this holiday for the last 12 months, eager to splash out on my young adult children before they no longer wanted to holiday with me. This was to be their dream holiday, to make up for a lack of holidays for more than three years. Our last family vacation had been in July 2016 in Darwin. This time we were going to the United States. They were 18 and 20, and top of their wish-list was Orlando Disney World. Little did I know these were to be the last days of our old life, a life not consumed and changed forever by the pandemic. Nor would I have guessed that the US, ranked first in the Global Health Security Index for pandemic preparedness, would fail so badly or that Florida would be among the worst affected parts of the country, with casual workers driven to homelessness when Disney World closed its doors in 2020. Who could have guessed that in the span of two years the life expectancy in the US would drop by the same amount as a result of the COVID-19 body count? When the boarding call came, I scanned the news quickly on my laptop, aware that we would have a long flight without access to news. I spotted the news item about Wuhan: a small cluster of cases of an unknown pneumonia. The World Health Organization (WHO) was saying that it was not transmissible between people.

Just three weeks earlier I had been in the US running ‘Pacific Eclipse’, a biothreat simulation of an unknown epidemic that arises in the Pacific and becomes a pandemic. With a high-powered group of participants from the WHO, the US Centers for Disease Control and Prevention, US IndoPacific Command, UK bioterrorism experts from Porton Down and others, we exercised the war games of a pandemic in Washington, DC. The scenarios we created in the simulation exercise included stranded cruise ships full of infected passengers being denied safe passage in global waters, mass quarantine, travel bans, case finding and isolation of infected people, contact tracing, national interest overriding global health, and even a US election which impacted on the pandemic. Little were we to know that within months all of these elements would actually come to pass with COVID-19.

In the Pacific Eclipse simulation, the infection in question was smallpox. Although we had an effective vaccine, not all countries did. And those that had the vaccine held onto it, leaving the pandemic to spiral out of control in mega-cities in Asia. As a result, instead of being contained within a year, the pandemic went on and on for eight years. Smallpox, biological warfare and bioterrorism have been research interests for me since 2006. At the University of New South Wales (UNSW) I co-designed a course called Bioterrorism and Health Intelligence, to share knowledge gained from a career in pandemics and biosecurity with students. I have worked with police and military around biosecurity for many years now. This has given me a perspective of the vital importance of interdisciplinarity in biosecurity. The response to a pandemic – whether natural or unnatural in origin – requires so much more than health expertise. It usually requires health, defence, law enforcement, emergency services, occupational health, engineering and many other disciplines to work together. This was one of the objectives of Pacific Eclipse – to teach participants to walk in someone else’s shoes and see the problem from a different perspective.

A couple of days after my family and I arrived in the US for our Disney World trip, the Wuhan story was still buried on page 3 and not yet headline news. I always keep an eye on outbreaks, aided by my epidemic observatory EPIWATCH, an artificial intelligence-driven system that scans news and social media for early signals of outbreaks. EPIWATCH has been my pet project since 2016. I’ve built it slowly, painstakingly, on a shoestring budget with deep knowledge of epidemics and an engine room of students. It is an artificial intelligence system but without funding or staffing, over the Australian summer holidays no one was present to check the signals it was spitting out. And, as we would later find out, the consequences of this were critical: had we been analysing the data at the time, we could have detected a signal for COVID way back in November 2019.

Almost as soon as my family and I got home, the COVID-19 epidemic exploded in China. It was clear there were many more cases than initially suspected, and that it was easily transmitted from person to person. Journalists immediately sought out my perspective on what was going on. For over 25 years I have been a regular voice of expertise in my field for the media, covering various outbreaks, among them the 2009 influenza pandemic. In early 2020 my phone was ringing hot from early in the morning until late into the night. I was getting calls from news agencies all over Asia, Europe and the US.

COVID-19 was upon us, ripping open many fault lines and exposing hidden truths about biosecurity. When the virus eventually hit, the impact in Australia was less than in many other countries. In a tactic reminiscent of the 1918 influenza pandemic, Australia used its unique island geography to keep the pandemic out for a whole year, shutting the international borders and buying time until vaccines were available – a honeymoon period of almost two years without facing the brunt of the pandemic as other nations did. In vaccination rollout and uptake, we lagged behind other countries. When the Delta wave hit in mid-2021, triggered by a failure to mitigate risk in airport transport, and compounded by a delay and lack of diversification in vaccine procurement, the Australian population was mostly unvaccinated. Still, we bought more time than other countries, enough to boast low death rates until the subsequent Omicron wave.

Many in Australia continue to cling to the glories of 2020, boasting about low mortality while simultaneously telling us the pandemic is over. By May 2022, the Australian Bureau of Statistics was already showing excess mortality from COVID, but our two-year period of grace – when Australia’s international borders were shut – will not be fully reflected in excess deaths data until 2023. In the US, meanwhile, the impacts of COVID-19 have been massive. By 2022, life expectancy had dropped by a whopping two years. In the first six months of 2022 alone, the Omicron wave resulted in the deaths of over 8000 people in Australia – dramatically more than the 2200 or so deaths in all of 2020 and 2021. Hundreds of these were in younger adults and some were in children, and the deaths far exceed the national road toll each year.

In 2022 Australia saw supply chains affected, supermarket shelves empty, delays in essential services – all due to mass workplace absence. In the pre-pandemic period, somewhere between 2 and 5 per cent of workers may be off sick at any one time. At the peak of the Omicron wave, the figure was around 20 per cent. Mass cognitive dissonance is on display when people complain of chaos at airports all over the world, wondering why their luggage didn’t arrive or their flight was cancelled. Part of the reason for such disruptions is that workers are sick with COVID-19. Vaccines on their own are not enough, and yet we have chosen not to use other layers of prevention, like ventilation, safe indoor air, masks, testing and tracing to mitigate the incidence of infection. Workplace absence, disruption to schools and households, hospitalisations and deaths are all a fraction of total case numbers. To reduce these, we must reduce transmission using a vaccine-plus strategy and ventilation.

Antivirals do exist, but there are not enough to be able to use them on a mass scale to add another layer of mitigation. Data are not yet available, but perhaps in the future rapid use of antivirals will cut the period of isolation and mean people can return to work sooner. They may even reduce the burden of long COVID. Yet to realise the promise of antivirals, testing is essential – they can never benefit the economy until testing is widespread, accessible and cheap or free. Giving people forewarning using digital tracing such as with QR codes will help. Meanwhile, good luck if you need to access health services or call an ambulance. Or if you get long COVID. In future, it is likely we will face a substantial burden of COVID-related chronic disease and disability. What this will do to our children is still unknown, but the available research suggests it is wildly reckless to sit by nonchalantly while the adults of tomorrow are infected en masse today, with the youngest still ineligible for vaccination.

The COVID-19 pandemic has brought with it disinformation, political meddling, counter-narratives and a flood of pseudo-experts willing to sell themselves for power and favour. It has also brought controversy about the origins of Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) – was it natural or unnatural? Did it arise from a lab leak at the high security lab in Wuhan? Determining the causes and patterns of epidemics requires detailed, careful analysis and expert knowledge. While even a child can tell if a building collapse is natural or unnatural – caused by an earthquake or a bomb blast – it’s not so easy for epidemics. Even the most seasoned experts cannot easily determine the cause of epidemics. Why does knowing the origin of an epidemic or pandemic matter? Do community members want to know if their loved one died of a natural epidemic or as a result of human error or terror? Does it change accountability? Understanding the history of pandemics, lab leaks and biological warfare is critical to knowing why the origins of epidemics matter. Lab accidents are exceedingly common, and biological warfare has been used throughout recorded history. Why then would unnatural epidemics suddenly become rare today, when the technology is vastly more enabling and accessible than it was even ten years ago?

The challenges of ascertaining the origins of an epidemic is partly due to established ways of thinking about outbreaks, but denial of unnatural origins of epidemics is a recurring theme throughout history. Too often, the basic question of whether a disease arose from nature or from human error or terror is not even posed. When it is, it is usually agressively shouted down. This is partly due to protection of vested interests by scientists, and partly due to the desire of those in power to prevent fear in the masses or obfuscate their own involvement. Information warfare has become more insidious and powerful with the widespread use of social media. The COVID-19 pandemic has amplified all of these factors and exposed many truths. Using the lens of history, I show that not everything is as it seems.

1

Believe The Unbelievable

SEPTEMBER 1950. AS CALIFORNIANS WERE WAKING UP to sunlight playing over San Francisco Bay, unbeknownst to them, a hazardous sea spray was in the air. A biological aerosol spray was being pumped silently toward the California coast from a ship in the bay. Continuing for six days, the spraying originated from a navy minesweeper as part of a Cold War biological warfare experiment using bacteria. The US military thought the bacteria was harmless, but within days, a strange outbreak of urine infections occurred in San Francisco. Eleven people were admitted to Stanford Hospital with a serious and rare type of infection that turned the urine red. One of them, Edwin Nevin, died of a rare bacterial infection of his heart valves. The doctors who treated the patients wrote the outbreak up in a medical journal as interesting and rare, but never questioned whether it was unnatural. In medicine, we start from the assumption that every outbreak is natural. We are not taught in medical school or in public health training to question the origins of outbreaks, only to respond, treat and control them. But to Edward Nevin’s family, it mattered whether their father died an unnatural and preventable death.

It would take 27 years and a lawsuit from Edward Nevin’s son, for the US government to finally reveal the cause of this outbreak: Operation Sea Spray. Operation Sea Spray was a US Navy biological warfare experiment on US soil, affecting local communities. From a naval ship moored in the Pacific Ocean off the San Francisco coast, the US Navy had released enough aerosolised bacteria Serratia marcescens and Bacillus globigii to infect nearly all of the city’s inhabitants. Taking samples, the military found that the bacteria had spread all over the city and suburbs beyond, from San Francisco to Sausalito, Albany, Berkeley, Oakland, San Leandro, Daly City and Colma. The residents of these cities would have inhaled millions of bacterial spores. Health authorities, however, were never alerted to the dangerous experiment. It is thought that this experiment may have also resulted in cases of pneumonia and heart valve infections, as well as permanent, long-term changes to the microbial ecology of the region.

Operation Sea Spray was conducted during the Cold War. It was one of several experiments into biological warfare conducted by governments on their own populations. The Cold War was a time when an arms race in biological weapons was underway, not only in the US and the Soviet Union, but also in the UK and other countries. Each country thought nothing of experimenting on their own people in the pursuit of military supremacy. The government seeing the masses as inconsequential, or even expendable is nothing new.

In the UK, similar experiments, including the ‘Sabotage Trials’ and DICE Trials, were conducted over communities between 1952 and 1975. In these cases, aircraft were used to spray bacteria over large areas without the knowledge or consent of the residents. Part of the larger Dorset Biological Warfare Experiments, these tests started with the spraying of the fluorescent chemical zinc cadmium sulfide, which accumulates in biological systems and can cause kidney, bone and respiratory problems with long-term exposure. Many families would later also report birth defects in children born in Dorset around the time of these experiments. Cadmium may also cause lung cancer. The US conducted similar experiments with zinc cadmium sulfide, and found that spraying over the mid-west of the country had widespread effects, with particles detected as far away as New York.

By the 1960s, the UK military expanded the DICE Trials to include the testing of bacteria such as Bacillus globigii and Escherichia coli (E. coli), with the aim of seeing how effective aerial spraying might be for biological warfare. They found that a single aircraft could infect an area of 16 000 square kilometres. Other experiments carried out on the unwitting populace in the UK and the US included releasing Bacillus globigii in subway train networks to see how far it would spread with the air currents generated by the movement of trains. As a bacterium, Bacillus globigii is similar to anthrax but thought to be safe. In 1966, in the middle of rush hour in the New York subway, the US Army dropped lightbulbs filled with more than 87 trillion Bacillus globigii bacteria in order to understand the behaviour of anthrax aerosols in the train tunnels. They wanted to determine how far the bacteria would travel and how easily it could be decontaminated. At the time, Bacillus globigii was thought to be harmless to people. Today it is known to cause infections in the blood stream and lungs, as well as meningitis in people with underlying medical conditions. During the New York experiment over a million commuters were exposed, but no data were collected on illness after the event. And no New Yorker who might have fallen ill was aware that they had been guinea pigs in a government-led bioweapons experiment.

Experiments conducted by governments on their own populations can be traced back even further. During the Second World War, the US tested chemical weapons on African American, Puerto Rican and Japanese American soldiers, using white soldiers as controls. The aim was to determine if there were racial differences in chemical injuries. The soldiers were put in chambers and exposed to Mustard Gas and other chemicals. Importantly, however, none of these experiments were documented on the soldiers’ official service records. As a result, this meant that some 60 000 soldiers subjected to deliberate chemical exposure were not eligible to receive medical care or compensation for the lifelong chronic injuries they suffered as a consequence. Some, however, did receive commendation certificates for ‘subjecting themselves to pain, discomfort, and possible permanent injury for the advancement of research in protection of our armed forces’. African American, Puerto Rican and Japanese American troops were considered ‘lesser’ and untrustworthy, were segregated and generally not allowed to have weapons, but assigned menial tasks. In 1993 the experiments were declassified, but it was impossible to track all the victims, because official records were never kept. Eventually, in the 1990s, surviving victims were paid benefits. But only 193 out of about 2000 claims received compensation. More recently these events are depicted in the brilliant Amazon Prime series Them which uses the horror genre to show the lives of an African American family who move into a white neighbourhood in Los Angeles in the 1950s. It touches on the chemical weapons testing on African American soldiers.

During the Second World War the UK similarly experimented with biological and chemical warfare. In 1943 a biological weapons plan, with the aim of releasing anthrax in Germany, began. The British government purchased Gruinard Island off the Scottish coast as the test site. Sheep and cattle were placed on the island as the test subjects, and teenagers were hired to help with the experiments. At least 22 anthrax bombs were made to rain on Gruinard Island and all the animals were observed to die within three days. Worse still, the carcasses of infected animals washed ashore, infecting livestock on the mainland. The government further exacerbated the effects by collecting dead animals, putting them in caves and then using explosives to get rid of the evidence – this backfired and resulted in anthrax being disseminated onto the mainland from the blasts. Gruinard Island was assessed to be so highly contaminated that it would be uninhabitable for at least 100 years. Documents detailing what really happened there were not declassified for more than 50 years. By 1987, however, after decontamination, the island was deemed fit for habitation. After the Second World War, British scientists went even further by conducting open sea testing of anthrax in the Caribbean. It was not until years later that anyone had any clue about these and other experiments, following their disclosure by governments. This demonstrates the tendency of governments to hide shocking secrets, as well as the inability of health experts to recognise unnatural outbreaks occurring in plain sight.

A very unusual outbreak

Being able to identify and analyse unnatural outbreaks is essential for the effective management of epidemics. This critically important point is one that I always drive home to my students. In a course I designed at the UNSW entitled ‘Bioterrorism and Health Intelligence’, I take students through an outbreak of salmonella in the US. The exercise uses as a case study a real outbreak, and I provide sequential data on it, along with the conclusions of the Centers for Disease Control and Prevention and local public health authorities. I ask the students to analyse the outbreak and make their own conclusions. The circumstances are as follows: in 1984 hundreds of people in a city in Oregon started getting sick with gastroenteritis. All the patients had eaten in at least ten different restaurants. I walk the students through the investigation. We look at the pattern of foods eaten by those who did and did not get sick, but there is no common ingredient or food – not the eggs, or the milk, the water supply or any other product. The inspection of affected restaurants show sanitation, water and food preparation to have been reasonable. All of the restaurants had a salad bar, and in ones that served the same food in private dining rooms, only people who ate from the public salad bar got sick.

The outbreak strain of salmonella was an unusual one, quite different from other salmonella