The real reason to panic about China’s plague outbreak

The Chinese government's response to this month's outbreak of plague has been marked by temerity and some fear, which history suggests is entirely appropriate. But not all fear is the same, and Beijing seems to be afraid of the wrong things. Rather than being concerned about the germs and their spread, the government seems mostly motivated by a desire to manage public reaction about the disease. Those efforts, however, have failed—and the public's response is now veering toward a sort of plague-inspired panic that's not at all justified by the facts.

On Nov. 3, Li Jifeng, a doctor at Beijing Chaoyang Hospital, the capital's key infectious diseases treatment and quarantine center, attended to a middle-aged man who was struggling to breathe and his wife, who was also running a high fever and likewise gasping for air. The couple had been ailing for at least 10 days by the time Li saw them. They had initially sought care some 250 miles north of China's capital in Inner Mongolia, a frigid cold region that straddles the borders of China, Mongolia, and North Korea, before being sent to Beijing for observation.

So far, so good, for China's response. More ominous, however, was what happened next. Li's WeChat social media posting describing the couple was quickly deleted. Meanwhile, the government officially informed the World Health Organization (WHO) about the cases, as it was required to do, but only on Nov. 13—after they were already reported by journalists around the world.

If the goal was to avoid stirring panic at home, the effect may have been the opposite. In the absence of clarifying, calming information from their government, Chinese people have been venting fear and concern on Weibo and other social media platforms. Their fear may be fueled by the role played by Chaoyang Hospital, which Beijing residents remember well from the 2003 SARS epidemic, when the authorities hid victims of that epidemic in the hospital, denying for weeks that the virus had even reached Beijing.

Amid the growing panic about the plague, the irony is that it far outstrips the real risks. Despite its devastating impact on human history, Yersinia pestis need not inspire fear or death in 2019. That it still causes the latter in the age of antibiotics is proof of public health and political failures, not to the inherent virulence of the microbe. That it causes the former is mostly due to misunderstandings about the relevant history.

There have been three great plague pandemics in human history caused by the bacterium Y. pestis, spreading from Siberia and Mongolia, across Asia, and into Europe, the Middle East, and Africa. The first began in A.D. 541 within the Roman Empire, lasted two centuries, and was dubbed the Justinianic Plague. The second, the Black Death, spread from Asia into Italy in 1346 and persisted for 400 years, infecting most of the European population with such devastating outcome—50 million people died on a continent then inhabited by 80 million—that for centuries historians referred to it as the Great Mortality. The third pandemic began in the 1850s in China, spreading across Asia with such ferocity that India, alone, lost 20 million people.

Since the invention of antibiotics, the threat of a fourth pneumonic plague pandemic has dissipated, but the microbe continues to evoke profound public fear. For example, in 1994 I was in the Gujarat epicenter of a pneumonic plague epidemic in India, where the actual numbers of laboratory-confirmed infections were relatively small. But panic sparked a national hysteria in which every cough and fever seen from the Himalayas to the beaches of Goa were diagnosed as plague, filling hospital beds nationwide, causing a run on antibiotics, and spawning dark conspiracy theories about Pakistani, American, and Russian bioterrorism.

From 2010 to 2015, there were 3,248 plague cases reported worldwide, with 584 deaths. Those numbers jumped with the Madagascar outbreaks in 2017 and 2018. Tragically, modern plague epidemics too often go unrecognized, and individuals are left untreated until Y. pestis has so devastated the human body that antibiotics cannot reverse the damage to the lungs, kidneys, and cardiovascular system. Then, according to WHO, fatality rates are between 30 and 100 percent, with blood (septicemia) and pneumonic cases having the highest death rates. Which of the three forms of plague an individual will experience—bubonic, pneumonic, or septicemic—is usually determined by how the person was initially infected. The milder bubonic form is usually the result of bites from Y. pestis-carrying fleas. More dangerous pneumonic plague is inhaled, typically from the coughs of another infected person, and swiftly spreads inside the lungs to cause life-threatening pneumonia. And the very rare septicemic form, which is almost always fatal when untreated, occurs when plague bacteria enter the bloodstream, sometimes through an opening in the skin, rapidly spreading throughout the body.

Since 1990, the African island nation of Madagascar has suffered bubonic and pneumonic plague outbreaks every year, occurring seasonally between late August and March, with an annual average of 200 cases, about a quarter of which prove fatal. In 2017, the so-called "black year," Madagascar recorded more than 2,400 cases, with 200 deaths, despite the bacteria's vulnerability to antibiotics. The seasonality of the disease in Madagascar is likely linked to surges in the island's rat population during heavy rains. Some scientists think that plague's life cycle in rodents and fleas will be affected by climate change, leading to increased outbreaks amid global warming, but the picture is complex and heavily debated.

The bacteria are endemic across much of Mongolia and the former Soviet countries in central Asia. As part of Mao Zedong's Great Leap Forward, more than 1.5 billion rats were killed in huge peasant campaigns in hopes of eradicating plague. During the mid-20th century, the Soviets conducted hundreds of programs, employing tens of thousands of people in hopes of eliminating the rodents and fleas that carry Y. pestis—all without lasting success.

In late April, a Mongolian couple contracted plague near Ulgii, not far from the Russian border, after eating the raw meat of an infected marmot—a squirrel-like animal that burrows in the steppes. A quarantine was put in place after the couple's deaths, when lab results confirmed the couple had the plague, and nearly 150 people were isolated or quarantined, including airplane passengers arriving from the region in Ulaanbaatar, the country's capital. The couple, according to local health authorities, died of multiple organ failure caused by septicemic plague.

Russia for decades has claimed invention of a successful plague vaccine, but it has never been available to the rest of the world, and its efficacy is dubious, according to Paul Mead, the chief of the Bacterial Diseases Branch of the U.S. Centers for Disease Control and Prevention (CDC) in Fort Collins, Colorado. Several antibiotics are very effective in lieu of a vaccine, taken to prevent infection—chiefly, doxycycline and fluoroquinolones. The drugs very successfully treat infection if they are administered within the first hours after infection. It is also easy to prevent person-to-person transmission of Y. pestis with hand-washing and use of basic face masks. But without these inexpensive measures in place—low-cost prophylactic antibiotics, hand hygiene, and masking—the bacteria can be very contagious with proximity to a coughing victim of pneumonic plague.

Lowering the risks, however, requires transparency on the part of public health authorities. China's National Health Commission has assured WHO, according to an agency spokesperson, that a robust effort is underway to find and monitor all individuals who have been in contact with the Beijing couple, both in Inner Mongolia and during their travel to Beijing. The Chinese Center for Disease Control and Prevention, modeled closely after the U.S. CDC, has indeed proved skilled in disease surveillance. But given the Chinese government's public health history—covering up the 2003 SARS epidemic even as it traveled to 30 other nations, denying the spread of the dangerous H5N1 influenza in the country for years, and stifling social media accounts of outbreaks—a fair amount of caution and skepticism is merited.

Laurie Garrett is a former senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize winning science writer.