Monkeypox: A new day, a new killer pandemic, right? Not exactly. Three biological danger signs can help us decide whether it’s time to sound the alarm or keep our cool.
August 4, 2022
By Wendy Orent
We don’t always know where pandemic threats come from, but we do know that, with nearly eight billion people on the planet, they’re always somewhere just beyond sight. We also know that not all germs are created equal. No matter where they come from, what counts is how they behave once they enter human populations: how sick they make us (virulence), how easily they spread (transmission), and whether they spread silently, without warning (stealth). Calculating the threat is something that even infectious-disease experts find tough, however. H5N1 avian flu, hantavirus, Ebola, West Nile, SARS-CoV-1, H1N1 swine flu, Covid-19, monkeypox. Which diseases have pandemic potential, and which are likely to sputter and die?
Some infections are truly limited—dangerous under local circumstances but unlikely to cause shutdowns or massive death. However ominous West Nile and Zika initially seemed, they’re mosquito-borne diseases whose scope is restricted by the availability of screens and air-conditioning. Spillovers from animal populations, such as the bat coronavirus that killed three cave miners in China in 2012, generally go nowhere because they’re ultimately adapted to animals, not us. SARS-Cov-2, the virus that causes Covid and can be transmitted through the air, is one kind of threat. Monkeypox, a rodent disease that, in the past, only sporadically infected people in West and Central Africa and that spreads only through direct contact, is quite another.
The ur-text for the worst kind of pandemic is the Black Death, the fourteenth-century outbreak caused by the plague germ Yersinia pestis. Everything else, even Covid, pales in comparison: Covid has slain its millions, the Black Death its tens of millions. The death rate from Covid hovers between 1 and 2 percent in the United States and in some nations is as high as 5.6 percent.
But the Black Death, uniquely virulent and transmissible, burned across Europe, eastern and central Asia, the Muslim world, North Africa, and Russia for seven years. At least 25 million died in Europe alone.
Without antibiotics, Yersinia pestis kills 60 to 100 percent of its victims, depending on how it spreads. Untreated pneumonic plague transmitted by aerosol is always fatal; flea-borne bubonic plague, the mild form, kills “only” 60 percent of victims without access to the antibiotics of today. Much of the Black Death was pneumonic. When the outbreak subsided, in 1353, perhaps 30 to 50 percent of those in Europe and other afflicted regions lay dead. The Black Death shows us just how bad things can get.
The real threat to the developed world is from lung-borne diseases, those spread by respiration, because you can’t stop people from talking, coughing, breathing.
The Black Death gives us a helpful context for understanding novel infectious threats. From HIV and the AIDS pandemic to Ebola and Zika and now Covid-19 and monkeypox, how do we think about a new disease when we suddenly face it? Is it really a Black Death–level threat, or more like another flu—or something in between?
To evaluate how dangerous a novel disease can be, look to the three factors mentioned earlier: virulence
(deadliness), transmission (how a disease spreads), and, for an extra garnish of horror, stealth (the ability to spread silently from host to host).
Transmission is the major factor determining whether the disease it causes can become pandemic. Some diseases spread sluggishly, some explosively, and some (like tetanus, rabies, or anthrax) don’t spread from human to human at all. With the outbreak of a novel coronavirus in 2003, later called SARS, it soon became evident that because the disease spread late in the course of infection, and mostly in hospitals, it would never explode out of control. Enabled by modern transport, it popped up in scattershot fashion around the world, infecting around 8,000 people and killing 774. But its inefficient spread allowed the ancient tools of isolation and ultimately quarantine to drive it off the earth.
Other new pathogens spread in still more limiting ways, using insects—fleas, ticks, mosquitoes—as vectors (carriers). The vector must get from one host to another, and in the Western world, well protected in general by screens and air-conditioning, that’s not so easy to do. This is why malaria, dengue, yellow fever, and Zika, despite how deadly they can be, have never found a foothold in modern Europe or North America. Other diseases, like cholera, are waterborne, and their spread is limited by modern sanitation. The real threat to the developed world is from lung-borne diseases, those spread by respiration, because you can’t stop people from talking, coughing, or breathing.
But transmissibility itself isn’t enough to bring the world to its knees. The rhinoviruses, adenoviruses, and human-adapted coronaviruses are all highly transmissible, but they don’t shut societies down. Something else is needed, something the Black Death had to the maximum: virulence, or lethality. Deadly diseases abound in the world: Rabies, Hendra, Nipah, leptospirosis, Legionnaires’ disease, and tetanus are all virulent and may kill many or, in the case of rabies, virtually all their victims. But their assaults generally either end with the victim, like anthrax or rabies, or spread sluggishly at best.
The Black Death was different. It was both highly transmissible and lethal, which is why it remains engraved in history as a single, traumatic, fracturing event, a pandemic that broke the world. Virulence and transmissibility must both be relatively high for a pathogen to emerge as a powerful threat. Fortunately, high virulence and high transmissibility very seldom coexist, and only once in as hideous and destructive a way as our medieval ancestors experienced in the mid-fourteenth century.
Diseases that are virulent but not transmitted efficiently can, however, become deadly local
threats, as virologist Angela Rasmussen of the University of Saskatchewan points out. Ebola, a deadly virus spread by exposure to blood and other bodily fluids, isn’t a pandemic threat because it doesn’t have the capacity to spread via respiratory transmission. Yet it has caused thousands of deaths locally in West Africa because of the intimate way that people in Sierra Leone and other countries in the region care for their sick and their dead, whom they carefully wash, exposing themselves to infected bodily fluids and keeping chains of infection going. Ebola is a highly virulent disease with tremendous capacity for local disruption, and it shouldn’t be minimized simply because it’s not highly transmissible. Still, the American panic over Ebola in recent years has been totally misplaced; despite hysterical articles warning that the virus could “go airborne,” diseases have never been known to change their mode of transmission, as Columbia University virologist Vincent Racaniello points out. The real concern should have been for the people of West Africa, facing a deadly threat and dying by the thousands, not for the Western world.
On the other hand, influenza, which is only moderately virulent (common strains have a mortality rate of 0.1 percent), causes tens of thousands of deaths worldwide each year because flu spreads effectively through airborne transmission. The reason the 1918 flu rivaled the Black Death in its destructive force was that, despite a mortality rate of “only” 2.5 percent, it infected virtually the entire planet, leaving 20 million to 50 million dead.
Covid-19, the pandemic disease caused by the novel coronavirus SARS-CoV-2, is both virulent and explosively transmissible, making it the deadliest pandemic in living memory. While it doesn’t approach the mortality of Ebola or the plague, it still has an approximate case fatality rate of about 1 to 2 percent, depending to some extent on the strain, on local conditions, on the age and health of the patient, and on whether people are vaccinated. Worse, people can be infected more than once. Worse still, perhaps 20 percent of survivors, according to some estimates, suffer long-term effects—cardiac, vascular, neurological, renal, pulmonary—for months or years.
But the real accelerant, the singular weapon, that has turned Covid into an uncontrollable pandemic is something it shares with the Black Death (and, incidentally, with polio): the ability to spread by stealth—that is, by people who carry the infection while appearing well. Those who fled the Black Death spread it while asymptomatic, and presymptomatic people spread SARS-CoV-2. Stealthy transmission is another pandemic danger signal, Louisiana State University virologist Jeremy Kamil says.
Stealthy, virulent, and transmissible, Covid still affects our lives. But more than two and a half years since its appearance, another disease has sprung up in its shadow: monkeypox.
Stealthy, virulent, and transmissible, Covid still affects our lives. But more than two and a half years since its appearance, another disease has sprung up in its shadow: monkeypox. This well-known rodent virus, misnamed because its true reservoirs are likely small rodents like rats and squirrels, used to be confined largely to West and Central Africa. It was first recognized as a human disease in 1970, though it is certainly much older. The blisters and pustules that characterize monkeypox look like smallpox, though monkeypox patients also have swollen glands. Unlike smallpox, however, monkeypox has never spread efficiently.
Notably, victims of monkeypox have traditionally been children surreptitiously hunting small animals like squirrels and rats, according to John Huggins, who studied the disease for many years while at the U.S. Army Medical Research Institute of Infectious Diseases. “Young children catch small rodents and eat them out in the jungle,” he explains.
There are two clades, or distinct genetic lines, of monkeypox. The one we are seeing in the United States and Europe now is known as the “West African” clade, which has a mortality rate of around 1 percent, comparable to variola minor, a mild strain of smallpox that has been eradicated. The so-called “Congo Basin” or “Central African” clade, which Huggins studied, kills about 10 percent, comparable to most African outbreaks of smallpox.
That’s where the similarity to smallpox ends because monkeypox, which is a spillover from rodents, is not a human-adapted disease. Where monkeypox spreads within a single household, the first case, caught directly from an animal, has the highest level of virus. That gradually drops off as the virus spreads within the family. Unlike smallpox, monkeypox seems to spread not via aerosol but in large respiratory droplets, so transmission requires close contact.
Huggins has always worried about what would happen if monkeypox entered a large, crowded city where a dense population might allow the evolution of more effective transmission. Is that what we’re seeing now? Probably not just yet.
Monkey pox is no Covid, and it is certainly no Black Death. More than 22,000 cases have been reported worldwide, and there’s no evidence to date of significant change toward greater virulence or transmissibility. While monkeypox doesn’t appear to be sexually transmissible like HIV or syphilis, it clearly spreads through intimate contact via skin and large respiratory droplets. Despite a lot of speculation to the contrary, monkeypox virus has not been shown to float or hang suspended in the air like SARS-CoV-2.
Where does that leave us with this disturbing disease? Monkeypox is frightening and painful. While the outbreak in the West is hardly as virulent or transmissible as Covid, let alone the Black Death, it is stealthy: People may have nonspecific flulike symptoms, fevers, swollen glands, and lesions in the throat (which appear before the skin pustules erupt) without realizing they have monkeypox, and in this early phase they can already transmit it to someone else.
Monkeypox may not be a second Covid, but governments and public health officials are not reacting swiftly enough to break the chains of human transmission. We can never eliminate monkeypox, but we can drive the pathogen back into its animal reservoir in the wild. As with Covid, public health messaging has not been informative or simple enough; testing widespread or accessible enough; vaccines available enough. The chains of transmission go on.
We haven’t seen the last of pandemic diseases because the conditions that give rise to them remain. In the wake of global warming, animal species are pried from their usual niches and carry infections elsewhere. Insect vectors expand their ranges and the reach of the pathogens they carry. We are knit together as a global community, and the monkeypox that once intermittently plagued Central Africa has reached out to us in the West. Worse, we’ve created conditions that forge new, deadly livestock diseases, like African swine fever, Newcastle disease, foot-and-mouth disease. The wild animal markets found in Southeast Asia spawned both SARS-1 and SARS-2 and remain ongoing threats for the adaptation and evolution of more pathogens.
Whatever the source of a new disease, our response is at least as important as the disease itself. We should reject blind panic over threats that aren’t virulent, transmissible, or stealthy enough to cause a deadly outbreak. There’s no point in panicking over monkeypox; it won’t force the planet into lockdown, though it stands to make many lives miserable. But if scientists find another new disease that transmits explosively, kills a significant percentage of people who contract it, and—worst of all—spreads from asymptomatic people, we’re in for another world of trouble. We would do well to recognize the danger signs and prepare now.
This story originally appeared on OpenMind, a digital magazine tackling science controversies and deceptions.
We tend to blame the glut of disinformation in science on social media and the news, but the problem often starts with the scientific enterprise itself.
June 2, 2022
By Joelle Renstrom
On November 8, 2021, the American Heart Association journal Circulation published a 300-word abstract of a research paper warning that mRNA Covid vaccines caused heart inflammation in study subjects. An abstract typically summarizes and accompanies the full paper, but this one was published by itself. According to Altmetrics, the abstract was picked up by 23 news outlets and shared by more than 69,000 Twitter users. On the basis of that abstract, a video on BrandNewTube, a social media outlet that circumvents YouTube’s anti-misinformation policies, pronounced Covid vaccinations “murder.” Sixteen days later, the American Heart Association added an “expression of concern,” noting that the abstract might not be reliable, and on December 21 it issued a correction
that changed the title to indicate that the study did not establish cause and effect, noting there was no control group nor a statistical analysis of the results.
This incident underscores a flaw at the center of the scientific enterprise. It’s all too easy to make outsize claims that sidestep the process of peer review. No publication should carry a standalone abstract, particularly one making such a bold claim, and particularly during a pandemic. But the problem goes much deeper than that: Even scientific papers that have passed through the intended safeguards of peer review can become vectors for confusion and unsubstantiated claims.
As we’ve seen again and again over the past two years, Covid-19 hasn’t been just a viral pandemic, but also a pandemic of disinformation—what the World Health Organization calls an “infodemic.” Many scientists blame social media for the proliferation of Covid-related falsehoods, from the suggestion that Covid could be treated by drinking disinfectants to the insistence that masks don’t help prevent transmission. Facebook, Twitter, TikTok, and other platforms have indeed propagated dangerous misinformation. However, social media is a symptom of the problem more than the cause. Misinformation and disinformation often start with scientists themselves.
Institutions incentivize scientists going for tenure to focus on quantity rather than quality of publications and to exaggerate study results beyond the bounds of rigorous analysis. Scientific journals themselves can boost their revenue when they are more widely read. Thus, some journals may pounce
on submissions with juicy titles that will attract readers. At the same time, many scientific articles contain more jargon than ever, which encourages misinterpretation, political spin, and a declining public trust in the scientific process. Addressing scientific misinformation requires top-down changes to promote accuracy and accessibility, starting with scientists and the scientific publishing process itself.
Universities want their scientists to win prestigious grants and funding, and to do that, the research has to be flashy and boundary-pushing.
The history of the scientific journal goes back hundreds of years. In 1731 the Royal Society of Edinburgh launched the first fully peer-reviewed publication, Medical Essays and Observations, initiating what has become the gold standard of credibility: vetting by experts. In the traditional model, scientists conduct original research and write up their findings and methodology, including data, tables, images, and any other relevant information. They submit their article to a journal, whose editors send it to other experts in the field for review. Those peer reviewers evaluate the scientific soundness of the study and advise the journal editors whether to accept it. Editors may also ask authors to revise and resubmit, a process that takes anywhere from weeks to months.
By 2010, most traditional scientific journals also had digital counterparts. The “open access” movement makes roughly 1/3rd of those available to the public for free. Meanwhile, the number of science publications and the number of published papers increased dramatically, and most academic institutions established themselves on social media to help promote the work of their researchers.
In this new world, scientific journals and scientists compete for clicks just like mainstream publications. Articles that are downloaded, read, and shared the most receive a high “impact factor” or Altmetric Attention Score. Studies show that people are more likely to read and share articles with short, positively worded, or emotion-invoking titles.
The rating system can’t help but affect scientists’ publications and their careers. “Many [scientists] are required to achieve certain metrics in order to progress their career, obtain funding, or even keep their jobs,” according to Ph.D. candidate and researcher Benjamin Freeling of the University of Adelaide, who was lead author of a study on the topic, published in the Proceedings of the National Academy of Sciences in 2019. “There’s less room for a scientist to work on a scientific question of immense importance to humanity if that question won’t lead to a particular quantity of publications and citations,” he wrote in an email to OpenMind. Valuing exposure above the scientific process incentivizes sloppy and unethical practices and demonstrates British economist Charles Goodhart’s Law: “When a measure becomes a target, it ceases to be a good measure.”
University of Washington data scientist Jevin West, who studies the spread of misinformation, says that university public relations offices responsible for press releases and other media interactions “also play a role in the hype machine. Universities want their scientists to win prestigious grants and funding, and to do that, “the research has to be flashy and boundary-pushing.” PR offices may add to that flash by exaggerating the certainty or implications of findings in press releases, which are routinely published almost verbatim in media outlets.
Many reporters don’t distinguish between unvetted preprints and formally published papers; to casual web sleuths, the two can appear nearly the same.
The demand for headline-worthy publications has led to a surge in research studies that can’t be replicated. Results of a reproducibility project published by the Center for Open Science found that only 26 percent of the top cancer studies published between 2010 and 2021 could be replicated, often because the original papers lacked details about data and methodology. Compounding the problem, researchers cite these nonreplicable studies more often than those that can be replicated, perhaps because they tend to be more sensational and therefore get more clicks.
Most readers, including journalists, can’t discern the quality of the science. Yet it’s “taken forever for the publishing community to provide banners on the original papers” to signal they “might not reach the conclusion readers think,” West says. Tentative or unsubstantiated claims can have profound social impacts. West references a one-paragraph letter written by two physicians and published in the New England Journal of Medicine in 1980, which he regards as largely responsible for the current opioid crisis. The authors asserted that “addiction is rare in patients treated with narcotics,” but they provided no supporting evidence.
It took 37 years before the New England Journal of Medicine added an editorial note warning that the letter had been “heavily and uncritically cited,” but neither a warning nor a retraction can put the misinformation genie back in the bottle, especially given the letter’s decades-long influence on narcotics prescriptions. What’s more, readers can still access misleading studies, and researchers continue to cite them even after they’ve been retracted because they either don’t know about a retraction, or don’t care.
The rise of preprints, scientific papers that have yet to be peer-reviewed, has generated further debate about the proper way to communicate scientific research. Some people celebrate preprints as a way to invite advance feedback and disseminate findings faster. Others argue that so much unvetted material adds to the misinformation glut.
Preprints accounted for roughly 25 percent of Covid-19–related studies published in 2020. Of those preprints, 29 percent were cited at least once in mainstream news articles. Take the infamous example of ivermectin, a drug developed for treating parasitic infections. A preprint touting its efficacy in treating Covid-19 patients appeared on the Social Science Research Network (SSRN) server in April 2021, prompting widespread interest in and approval of the drug, including by governments in Bolivia, Brazil, and Peru. As people began taking ivermectin to treat or prevent Covid-19, scientists expressed concern about the data used in the preprint—data supplied by Surgisphere, a health-care analytics company whose unreliable data
had previously led to retractions of papers in The Lancet and The New England Journal of Medicine. The paper was removed from SSRN, and shortly thereafter Surgisphere shut down its website and disappeared.
The now-removed preprint paper inserted ivermectin directly into the political spin machine. What’s more, the hype and drama surrounding the drug obscured the critical uncertainty about whether it could actually treat or prevent Covid-19. (A subsequent study suggests that if taken soon after diagnosis, ivermectin can help prevent serious illness.) It also distracted from the important fact that the efficacy of any drug depends on timing, dosage, and other health and safety factors that people shouldn’t try to determine on their own.
Approximately 70 percent of preprint literature is eventually peer-reviewed and published, but what about all the rest, which never become anything more than preprints? Many reporters don’t distinguish between unvetted preprints and formally published papers; to casual web sleuths, the two can appear nearly the same. When unsubstantiated findings guide personal behaviors and policies, even a small number of faulty studies can have significant impact. A team of international researchers found that when first-draft results are shared widely, “it can be very difficult to ‘unlearn’ what we thought was true” —even when the drafts are amended later on.
Unlearning falsehoods is especially challenging given today’s oversaturated news cycle. Online news aggregators syndicate local and national publications and present readers with an endless barrage of information via notifications and emails. In this context, it’s hardly surprising that readers tend to click on splashy headlines and articles that confirm their preexisting beliefs. “Science is embedded in an information ecosystem that encourages clickbait and facilitates confirmation bias,” West says.
And when people try to explore the research behind the headlines, they run into barriers: Scientific articles are becoming increasingly hard to understand as researchers pack them with more jargon than ever. A group of Swedish researchers who evaluated scientific abstracts written between 1881 and 2015 found a steady decrease in readability over time. By 2015, more than 20 percent of scientific abstracts required a post-college reading level. A big issue is the heavy use of acronyms; as of 2019, 73 percent of scientific abstracts contained them. Scientists themselves sometimes avoid citing papers rife with jargon because not even they can confidently parse it. We’ve all heard of “legalese,” but “science-ese” can be similarly inscrutable and alienating to readers.
10 years ago, the debate was around whether scientists should spend their time engaging with the public. Now the question is how to do it.
Addressing the science-driven misinformation problem will require a “profound restructuring of how the science ‘industry’ works,” Benjamin Freeling says. One recommendation is for journals to help readers see the preprint as a work in progress, not as the end result. Critical care physician Michael Mullins, editor-in-chief of Toxicology Communications, referred to a 2020 paper about the effects of hydroxychloroquine on Covid patients that appeared on the preprint server medRxiv
and was published in the International Journal of Antimicrobial Agents that same day without undergoing peer review. Many people (including the president of the United States) regarded the study as complete, underscoring the danger of scientists using preprints to circumvent peer review.
One change that statistician Daniel Lakens of Eindhoven University of Technology advocates is to implement a system of “registered reports,” which involve peer review and acceptance of a study’s design, methodology, and statistical plan before data are collected and regardless of what the data ultimately suggest. These reports would be pre-accepted for publication when the final data and analysis are complete. Registered reports would combat the tendency to publish papers with greater potential for publicity and clicks because publication would revolve not around the outcome but around the process. In 2020 the journal Royal Society Open Science initiated a rapid Registered Report system that allows for ongoing documented revisions. Many other journals have followed suit, attempting to balance the need for a faster review process with the need for accuracy. If publications relied on process rather than the outcome or the potential for clicks, scientists could focus on and produce better science.
As for the academic public relations machine, Jevin West believes scientists should be held accountable for the text in university press releases. Carl Bergstrom, a biologist at the University of Washington who is active in public outreach, suggests that scientists sign off on press releases before they’re sent out, putting those releases through their own form of scientific review.
Scientists aren’t responsible for the critical thinking skills of the average reader or the revenue models of journals, but they should recognize how they contribute to the spread of misinformation. To address the jargon problem, scientists could use fewer acronyms and include “lay summaries,”
also known as plain-language summaries. Some publications now require these, but they could go further by requiring glossaries of technical terms and acronyms, jargon cheat sheets, or other types of decoders necessary for understanding a study, especially for open-access and preprint articles. Freeling’s advice is more blunt: “Try better writing.”
Scientists can also communicate more effectively with the public by harnessing social media. Freshwater ecologist Lauren Kuehne, whose work includes a devotion to science communication, advocates informative blog posts, Twitter threads, TikTok videos, and public talks to build relationships. But open communication comes with its own issues, especially balancing a desire for influence with trustworthiness. Organizations such as the American Association for the Advancement of Science (AAAS) offer workshops
and communication tool kits on effective public science communication, but scientists have to pursue that information on their own. The good news, says Kuehne, is that “10 years ago, the debate was around whether scientists should spend their time engaging with the public,” whereas now the question isn’t “whether it’s important, but how to do it.”
Direct public engagement is the best way to help people understand that even the most canonized scientific facts once were subject to debate. Making the scientific process more transparent will expose flaws and may even beget controversy, but ultimately it will allow scientists to strengthen error-correcting mechanisms as well as build public trust.
That science works despite the problems noted here is, as Bergstrom puts it, “amazing.” But the ability of science to transcend flaws in the system shouldn’t be amazing—it should be standard. Let’s save our amazement for the discoveries that emerge because of the scientific enterprise, not in spite of it.
This story originally appeared on OpenMind, a digital magazine tackling science controversies and deceptions.
Science Communication Lab – Indonesia
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