On November 16, 2002, a 45-year-old man was admitted to hospital in Foshan City in Guangdong, China. His condition was consistent with pneumonia, a high fever, muscle aches, shortness of breath, coughing and respiratory difficulties.
Four other members of the patient's family soon fell ill with similar symptoms. Three weeks later, a 35-year-old man was brought from his home in nearby Heyuan to Guangzhou provincial hospital after becoming ill. He infected the doctor who had accompanied him in an ambulance, and then seven of the medical team treating him.
Whatever his illness, it was highly infectious: antibiotics proved ineffective, meaning that clinical strategy – which would later be replicated elsewhere – amounted to keeping him alive in the hope that his immune systems would fight off the disease.
Clusters of such outbreaks occurred throughout Guangzhou over the following months and, although physicians were acutely aware of the danger that the new, highly communicable disease posed, they were baffled as to its cause. Later analysis revealed that it was a coronavirus – the virus associated with the common cold. This information confused scientists: it's extremely rare for a coronavirus to kill human beings, yet around 15 per cent of those infected were dying.
According to David Quammen's book Spillover, over the next few weeks 28 cases were recognised in Zhongshan, 95km south of Guangzhou. Symptoms were similar to the earlier cases and included "severe and persistent coughing, coughing up bloody phlegm, and progressive destruction of the lungs, which tended to stiffen and fill with fluid, causing oxygen deprivation that, in some cases, led to organ failure and death."
Then the outbreak really took hold: two "super spreaders" distributed it beyond where it had been found up to that point. The first, Zhou Zuofeng, arrived at Guangzhou hospital with symptoms now familiar to the staff. He transmitted the disease to at least 30 healthcare workers before being transferred to a specialist hospital. On the way, he infected two doctors, two nurses and the ambulance driver. At the second hospital, 23 doctors and nurses, plus 18 other patients and their relatives and 19 members of Zhou's family, became ill, prompting staff at the hospital to name him the Poison King.
On February 21, 2003, Liu Jianlun, a nephrology professor and one of the doctors who had treated Zhou, travelled to Hong Kong to attend his nephew's wedding. While staying at the Hotel Metropole, in the heart of one of the city's busiest shopping districts, he began to feel ill. During his stay, Liu unwittingly infected a number of people who were staying in rooms on the same floor. One of them was a 78-year-old Canadian. On February 22, she boarded a flight for Toronto. Eleven days later, she died, but not before passing the condition on to her son. The virus then spread throughout the hospital where he was treated. Over the following weeks there were at least six transmission chains in Canada; 400 people became seriously ill, 25,000 were placed in quarantine and 44 died.
In late February the Centers for Disease Control – the US organisation that monitors and responds to emerging health threats – and the World Health Organisation (WHO) began to investigate.
However, scientists were working in the dark; they knew only that the disease was highly contagious, that it made those who contracted it become severely ill and that dozens of people had died (later – following an admission from the Chinese government – it would emerge that the number of deaths was in the hundreds).
There was no medication – treatment was limited to administering steroids to reduce inflammation in the lungs.
On March 12, following the news that one of its top epidemiologists had died after contracting the disease in Hanoi, the WHO issued a global health alert for what it called Severe Acute Respiratory Syndrome (SARS). It was the first time the organisation had taken such a step. The microbe responsible for the disease still hadn't been identified, prompting an unparalleled coming together of global research facilities and laboratories to pool resources. A month later, a team at the Michael Smith Genome Sciences Centre in Vancouver, Canada, announced that it had decoded the virus's DNA. The good news was that the virus wasn't mutating – its stability meant that it would be possible to develop a vaccine that could target the way in which its proteins latched on to human cells, although this would likely take years. Eventually, public health practices put in place across the world contained the virus.
The 2003 SARS epidemic infected 8,096 people worldwide, killing 744 of them. These are not big numbers compared to other pandemics – smallpox, black death and flu have killed hundreds of millions since they emerged millennia ago, and the swine flu outbreak of 2009 infected up to 89 million - but it offered a rapidly globalising world an insight into how quickly an outbreak of a killer disease can cross continents. The so-called Spanish flu pandemic that followed the first world war killed between 50 million to 100 million people. If there were a proportional outbreak today – when the global population is over seven billion – there could be upwards of 300 million deaths. SARS, although infectious, wasn't as virulent as first feared, but its effects were amplified by the way carriers moved across the world: there is no evidence that the Canadian woman who brought the disease to Toronto met the Chinese "super spreader" in Hong Kong. It is likely the virus spread through the air in a lift or via a point of contact such as a door handle. Such unfortunate encounters are now part of the modern world.
Once, pathogens could spread only at the speed at which human beings could walk. Now they can move between any major city on Earth within 24 hours, meaning that early detection – reading the very first signs of an outbreak of a virus such as flu, which has an incubation period of between one and four days – could be the difference between a localised and treatable situation and a global pandemic. Much is made of the role of technology in the spread of disease; after all, without air travel SARS would have probably remained localised in Asia, instead of spreading rapidly across the globe. Equally, however, governmental communication and co-operation – prompted by epidemiologists who make the significance of outbreaks clear through early detection – can mean that disease is contained and controlled. "If you catch a virus within one incubation period there will only be five cases – and you can stop it," says the epidemiologist Larry Brilliant. "If you wait seven incubation periods it will be in the thousands. You go a couple more and it's in the billions."
The 70-year-old knows something about the spread of disease, having led the WHO team in south Asia that eradicated smallpox. His mission now is to bring together government, the private sector and citizens to develop digital tools to detect outbreaks early. The four months it took for the global health community to mobilise following the outbreak of SARS could prove catastrophic should a more virulent disease emerge. Brilliant is clear about the stakes: "We're in a race against time."
One hazy Bangkok morning last November, Brilliant stands before a group of Thai health officials. He has slicked-back grey hair, a trimmed beard and, despite the warmth, he wears a black suit that causes him to perspire. He has wrapped an LED screen around his torso, which he has programmed with a Raspberry Pi. The red flashing lights make up letters that read: "DETECT DISEASES FASTER". Brilliant has a dry sense of humour and speaks calmly. He often places his hand on the person he is addressing and uses the phrase "but my question is..." to draw them in. He usually runs late, prompting his colleagues to inform him that meeting times are earlier than scheduled in order to guarantee his presence on time.
Brilliant is president of the Skoll Global Threats Fund (SGTF), an organisation funded by billionaire Jeff Skoll, the cofounder of eBay, that seeks to confront threats imperilling humanity.
Brilliant and the pandemics team – Mark Smolinski and Jennifer Olson ("I'm manager of pandemics, which is a really fun title," she says) – arrived the night before from Cambodia. The Thai Ministry of Health, those working in public health, telcos, Google Thailand, data analysts, academics, social innovators and technologists are all present.
Epidemiologists often use the word "zoonotic" – meaning diseases that can be communicated between humans and animals. This is because there is not one of them who doesn't think that the next global pandemic will originate from the blood of a wild animal. It might result from a pig that's been bitten by a bat in Thailand; it could be a monkey that's been killed and eaten in a Cameroonian rainforest. (The SARS outbreak was traced back to the civet, a cat-like wild animal eaten throughout southern China.)
Deforestation and urbanisation are bringing humans into contact with species and viruses that have, until recently, been deep in natural ecosystems. This close contact gives formerly unknown pathogens the opportunity to move to a new species: human beings. "Those who think that the sharing of vital fluids in sexual relations is the most intimate way that you can exchange genetic material with another person are wrong," Brilliant says. "The most intimate encounter you can have with another creature is to eat it." Brilliant says that the number of wild animals eaten in Africa per year is close to a billion. "Every cell in every piece of bush meat you're eating may represent a novel encounter between a human and an animal that harbours a virus." According to Brilliant, over the past 30 years, three dozen previously unknown viruses have jumped species – a phenomenon epidemiologists call "spillover".
The first quantitative analysis identifying risk factors for human disease emergence was conducted in 2001 by Louise Taylor, Sophia Latham and Mark Woolhouse at the Centre of Tropical Veterinary Medicine at the University of Edinburgh. "A comprehensive literature review identifies 1,415 species of infectious organisms known to be pathogenic to humans, including 217 viruses and prions, 538 bacteria and rickettsia, 307 fungi, 66 protozoa and 287 helminths. Out of these, 868 (61 per cent) are zoonotic," they wrote. But the part of the paper that is particularly alarming relates to so-called "emerging" pathogens – infectious organisms that, over the past two decades, have either been detected in humans for the first time, are increasing in incidence or are occurring in regions they had not previously occurred. Seventy-five per cent were found to be zoonotic. "This is substantially more than expected if zoonotic and non-zoonotic species were equally likely to emerge," Taylor et al write.
The key goals of the pandemics team at the SGTF are detecting an outbreak faster, verifying that it's a real sign and getting a connected network of people to talk about what's going on. That information can be gleaned from multiple public domain sources: news-article mentions, internet searches, social media, satellite imagery of hospital car parks (to see if there is an upswing in the number of vehicles), or monitoring the sales of cinema tickets to see if there has been a drop in purchases. Olson describes them as "indirect indicators that something is emerging in a population where maybe it's unclear, where there is no distinct diagnosed disease."
The widespread adoption of mobile technology in the developing world means that, increasingly, health authorities are building digital platforms to collect data. One of the projects that the team are focused on in Thailand is called DoctorMe, a free, personal healthcare mobile app. According to its developer, Opendream, it's been downloaded 250,000 times and has 30,000 active users. It was first launched in 2011 as an electronic health manual with contact details of over 1,000 hospitals. An updated version, released in April 2013, has push notifications to warn people about health crises. Users are also able to diagnose possible conditions by means of a digital questionnaire about their symptoms. The data is then sent anonymously to Google which analyses the symptoms and location of the users.
DoctorMehas been designed with an extremely simple interface – there is an image of a human body, users touch the point where they're hurting and they are then offered a series of prompts that could result in the app autonomously calling an ambulance. "In Cambodia we're working with a group that has a voice-based data-collection system," Olsen says. "So, even if a person in a rural area has a simple phone and they aren't texting yet, or the characters are so challenging it would be hard to text, they do a
'press 1 if you have a car, press 2 if you have a fever'." "In 2005 the WHO began to understand that these digital disease-surveillance systems were, in fact, more powerful than routine reporting systems or the occasional anecdote that was brought to them by a health minister," Brilliant says. Two years later, the organisation ratified a change in the relationship between disease responders and disease information gatherers and international regulations. "Previously, the WHO was prohibited from taking information from a digital system or an NGO and acting on it," Brilliant says. "The change made it absolutely necessary for the WHO to take notice of any report that came from a digital system and countries had a requirement to use systems, collaborate and to report diseases."
One of the first big-data approaches to public health was the Global Public Health Intelligence Network (GPHIN), a Canadian platform set up in 2000 as part of the WHO's Global Outbreak and Response network. The system monitors digital media in nine languages, searching for signals related to potential outbreaks of communicable diseases.
There are other, lo-fi approaches: one epidemiology training officer who gave a presentation at a SGTF event in Ho Chi Minh developed a scheme on three Indonesian islands where people have been hired to read local newspapers, which have yet to be digitised. The researchers enter disease terms into a database and then combine them with open-source tools such as HealthMap. Doing so, they estimate to have found 50 per cent of the recent outbreaks on the island. "That, to me, is the really exciting thing, thinking about how at one time it was only a big organisation with data that would create a digital disease-detection system," Brilliant says. "Now, anybody who thinks creatively is able to do that."
Perhaps the best known of these systems is Google Flu Trends, which Brilliant and Smolinski set up when they were working at Google.org, the tech giant's philanthropic wing. "We captured every keystroke ever entered into Google and we did hundreds of thousands of regression analyses to find what were the 30 or 40 or 50 search terms," Brilliant explains. "So these engineers capture all the information ever put into Google and match it against other data.
The CDC's report found 50 terms that could explain 98 per cent of the variation. Then they took those terms and they began watching it for a year to see if it matched CDC reports exactly. And, surprise, it matched it exactly – but it was two weeks earlier...
Now you have a breakthrough. Two weeks is a lifetime in fighting a disease."
Brilliant and Smolinski moved from Google to SGTF in April 2009 and decided to focus on participatory surveillance – essentially, people opting in and self reporting. The best known of which is Flu Near You, a US platform that allows users to complete a brief weekly health survey, to monitor flu activity in their area and find locations for vaccination. The idea for the project came when Smolinski was doing some work with Singularity University in Mountain View, California. "They have a challenge to create a project that will impact a billion people within ten years," he says. "One of the projects that the students were coming up with was they really wanted to understand how you could use Facebook to think about tracking genetic markers... When I saw [how] the next generation of kids was thinking about sharing their genomic data publicly, I thought, 'And we're afraid to ask people if they have a few symptoms of disease?'"
SGTF has awarded a grant of $1,125,000 (£680,000) to Connecting Organizations for Regional Disease Surveillance (CORDS), a non-governmental organisation with six regional disease-surveillance networks dedicated to detecting outbreaks early by sharing data, implementing emerging technologies and sharing best health practice. This kind of digital connection means that a doctor in Uganda can keep track of emerging pathogens in Vietnam, and a clinic in Bulgaria will be able to make a diagnosis on the basis of what has been learned in Laos. Disease can travel at the speed of a Boeing 777 – but data can move faster.
Brilliant and Smolinksi are standing on a crowded river taxi on the Chao Phraya River. Plumes of diesel billow from the back of the vessel as the pilot guns the engine to take off from the jetty at Sathorn Central, the main terminal. It's the week after the Thai festival of Loi Krathong and, as the boat heads up the busy river, hundreds of the decorations that are traditionally floated on water to mark the occasion, bob on the water.
When they disembark at Tha Tien pier, the epidemiologists can't help themselves – they examine the hygiene practices at the local food market. Smolinski approvingly watches two women sitting under umbrellas to shade them from the Sun. "The important thing is they're not mixing any meat," he says. "And it's all going into hot oil."
In the tropical heat Brilliant walks by the nearby Temple of the Emerald Buddha. He has read widely on eastern and western religions and often begins sentences with the words, "Have you heard the story of...?"
Brilliant's life is reminiscent of the title character's in the Woody Allen movie Zelig. His parents emigrated from eastern Europe to Detroit in the 30s and Brilliant was the first person in his family to go to college. A civil rights activist while at the University of Michigan, he met Martin Luther King in 1962 and travelled to Alabama and Mississippi to support voter registration.
It was this sense of social responsibility that caused Brilliant to embark on a career in public health. A week before he was due to begin his internship at Presbyterian Hospital in San Francisco, a trade publication published a photo of him and four other activists on its cover. The medical profession in the 60s was clubby and comfortable, reluctant to give up its privileges. When Brilliant arrived at work the first day, he found multiple covers of the magazine stuck to the wall: bullseyes had been drawn around his head and some had hypodermic needles stuck into them. Brilliant's punishment was to be assigned to the intensive-care ward for 96 hours straight. Five days later Brilliant and some other doctors organised a union and went on strike for better patient care. The hospital caved.
Brilliant was 26 and just finishing a surgical internship when he learned that he had cancer of the parathyroid gland, a rare form of the disease. Surgery was successful. He was taking time off to recover when, in November 1969, a group of Native Americans occupied Alcatraz Island in San Francisco Bay, in a symbolic act to do with land rights. During the stand-off with the government, which lasted 18 months, Brilliant hopped on a boat to the island and delivered a baby after hearing of its mother's plight. On his return he was met by television reporters and was offered a film role that, in turn, took him to London. He ended up on a bus full of people heading to what's now Bangladesh to help with disaster relief after a deadly cyclone. The group was denied entry to the country, so the bus diverted to Kathmandu.
There, Brilliant and his wife Girija went to live in an ashram studying with the Hindu mystic Neem Karoli Baba. This is where he first met Steve Jobs ("barefoot and shaven-headed"), with whom he forged a lifelong friendship. Years later Brilliant was an early investor in a company Jobs founded called Apple. Brilliant and Girija lived in the ashram for two years before his guru informed him it was his destiny to help cure smallpox. "He told me smallpox would be eradicated," Brilliant says. "I didn't know there was a smallpox problem."
Brilliant left the ashram and travelled to New Delhi where, once he had got a haircut and bought a new set of clothes, he was given a job by the WHO. He was the second hire. "It's preposterous what happened to me," he says. "It makes no sense other than it was the path that was determined."
Then, smallpox – a virus that has killed hundreds of millions – was endemic in India. Brilliant first encountered it with Bill Foege, who was in charge of the WHO programme. Foege is credited with devising the strategy of surveillance and containment that defeated the disease – he went on to head the CDC and work with the Bill and Melinda Gates Foundation. "The first kid they brought me who had smallpox, I said, 'Bill, we gotta get an ambulance, we gotta get this guy to the hospital',"
Brilliant says. "I was thinking like a clinician. And Bill said,
'There is no ambulance. There's no treatment. We have to stop this thing. We have to eradicate it. It can't be treated.' And I'm saying, 'Oh, no, come on, we gotta get him to the emergency room.
We gotta get him to ICU.' And Bill just said, 'Larry, if you want to be a public-health doctor you have to transform the love, the compassion you have and not think about a child's fever chart; you've got to think about epidemic curves and statistics. You've gotta be able to take your satisfaction from the derivative of actual cases.'" The initiative went on during the 70s through both immunisation and a vast public-health campaign that focused on early detection of symptoms. To eradicate it, WHO officials had to identify every single case – if they missed one, the disease could spread again. Health workers made over a billion house calls, visiting every home in India once a month. In October 1977, Brilliant visited Bhola Island in Bangladesh and saw the last ever case of smallpox. This was the first – and so far only – disease to be eradicated.
There are other highlights to Brilliant's career. He cofounded the Seva Foundation, which has restored eyesight to three million people; following a random meeting with playwright Arthur Miller in London, he joined a delegation negotiating an end to the Vietnam war with the Viet Cong leader Mai Van Bo; he served as a professor of International Health at the University of Michigan; set up one of the first net companies, Network Technologies International; cofounded The WELL in 1985 – one of the net's first communities – with Stewart Brand; served as personal doctor to the Grateful Dead's Jerry Garcia; took broadband firm SoftNet public and served as the CEO of other technology companies.
In Bangkok, Brilliant likes to visit the River City antique market, which is, he says, "the source of the best counterfeits in the world." He collects south Asian art and considers the goods on sale – glazed ceramics, Khmer terracotta, Islamic bronzes and Afghani pottery – with a gimlet eye. Speaking fluent Hindi, he charms a number of dealers. Once they establish his expertise and grasp of Asian history, he's invited into back offices where cards are exchanged and there are conversations about the contemporary art market. "My life doesn't make sense," he says getting into a bright pink Bangkok taxi. "I guess I like people. My answer to everything in life is always to say 'yes'."
Greg Williams is Wired's executive editor. He wrote about how successful retailers are combining off- and online shopping in 03.14
This article was originally published by WIRED UK
