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Welcome to Axios Future, where the only way I know it's Saturday is because the newsletter is out.

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Today's issue is 1,532 words, a 6-minute read.

1 big thing: How the war on disease made our world

Illustration: Sarah Grillo/Axios

The biggest pandemic in decades serves as a reminder of just how big a role infectious disease has played in human history — and will continue to play in the future.

The big picture: Without victory over infection, humanity wouldn't have developed the globalized and populous civilization of today. Yet that civilization is vulnerable to COVID-19, which can only be fought by decoupling the connections that underpin the modern world.

COVID-19 is, ironically, a function of the richer, more connected and more populous world created by the defeat of disease.

  • Medical technology like artificial ventilators will keep the death rate from COVID-19 lower than in past pandemics like the 1918 flu.
  • But the social distancing needed to slow its spread will exert a much worse economic toll than it would have a century ago because our much larger economy is far more dependent on global trade and uninterrupted human connection.
  • "Globalization is both a vulnerability and a reason why our response to this, even with all the economic pain, will be much more effective than it was in the past," says Charles Kenny, a senior fellow at the Center for Global Development and the author of a forthcoming book on the history of disease.

Background: For most of humanity's history, disease and infection kept a check on human development. Population growth, economic growth, even the spread of people across the planet — all were curbed by the threat of contagion.

  • As late as 1800, average global life expectancy was just 29 years. This wasn't because human beings couldn't live to an old age but because almost half of all people born died before their 50th birthday, mainly from contagion.
  • Death from disease in urban areas was so rampant that up until the 19th century, cities were only able to maintain their population through a constant influx of migrants to replace the dead.

All that began to change in the 19th century, with the sanitary revolution and later the widespread development of vaccines and antibiotics.

  • Untold numbers of lives were saved. Global life expectancy rose — to 71 years on average today — and with it, global population.
  • Freed from the constant reaping of their citizens from infection, cities exploded, their larger populations becoming engines of rapid innovation. Global travel became safer and with it, the global trade that has helped drive startling levels of economic growth over the past century.
  • "Our defeat of infection overcame the barriers to human development," says Kenny.

Yes, but: That defeat has been so total that we often take it for granted, especially in the developed world, where we are far more likely to die from heart attacks or strokes — conditions human beings rarely lived long enough to suffer from — than infectious disease. As a result, we've let our guard down.

  • Global vaccination rates have stagnated and declined for diseases like measles in recent years, partially driven by anti-vaxxers who have no memory of a world threatened by childhood diseases.
  • As antibiotic resistance grows because of overuse, we desperately need new drugs. Yet in January the World Health Organization warned the pipeline for new antibiotics was essentially dry.
  • And of course the explosive spread of COVID-19 has shown just how unprepared the world was for a contagious, new infectious disease.

The bottom line: The reason COVID-19 feels so disruptive is because our world was built on the idea that events like this no longer happen. We won't get that world back until we beat this disease. And we can't safeguard that world unless we ensure it won't happen again.

2. What a coronavirus exit ramp looks like

Illustration: Sarah Grillo/Axios

Americans are looking for an exit ramp away from the extreme social distancing brought on by the coronavirus, but that will require steps we're not yet prepared for, I write with my Axios colleague Caitlin Owens.

The big picture: Responsibly easing off of social distancing will only be possible as the number of new cases levels off, and will depend on extensive testing to avoid another surge in infections.

"The problem is that the next phase of containment is contingent on resources we don't have,” said Jennifer Nuzzo, senior scholar at the Johns Hopkins Center for Health Security.

Where it stands: If we're going to back off of aggressive measures like school and business closures, the next phase of the response would involve doing a lot of the things we should have done from the beginning.

  • That includes quickly identifying and isolating newly infected patients and identifying others they may have infected.
  • Places that house vulnerable people, like nursing homes, would still need strong oversight.

Yes, but: All of that requires fast, widespread testing, which the U.S. still can't do.

What's next: Syndromic surveillance — testing a random portion of the community — might help the U.S. get a better handle on the true prevalence of COVID-19.

  • Seattle has launched an effort to do just that, adapting an existing program that checks for influenza prevalence.

The bottom line: “The worst-possible outcome would be a second epidemic, a second wave…. We can’t afford to have this happen again,” said former FDA commissioner Scott Gottlieb.

Go deeper

3. How climate change and wildlife influence the coronavirus

Illustration: Sarah Grillo/Axios

The good news is, climate change is not directly at play with the coronavirus. The bad news: we humans are still root drivers in pandemics like this one, my Axios colleague Amy Harder writes.

Driving the news: Buying, selling and consuming wild animals, such as at the Wuhan, China, market where this novel coronavirus is believed to have originated, is increasingly spreading deadly infectious diseases, experts say.

By the numbers: Zoonotic diseases — those spread from animals to humans — have “quadrupled in the last 50 years, mostly in tropical regions,” according to a letter more than 100 wildlife and environmental groups sent to Congress this week.

The big picture: Scientists say these types of close encounters with disease-carrying animals are just one part of a complex relationship between humans and nature. Climate change has a massive, overarching impact on it all, though it’s a less direct connection than, say, wild animal markets.

Go deeper

4. AI in medicine may be overhyped

Illustration: Aïda Amer/Axios

A new review concludes that the claims that artificial intelligence is better than human experts at interpreting medical scans and images are likely overblown.

Why it matters: There's legitimate hope that AI could improve patient care and cut costs. But there's also a real risk that people could be hurt if biased or mistake-prone algorithms are rushed into medicine.

Background: One of the first commercial uses for AI in health care has been the work of interpreting medical imagery such as X-rays or CT scans. Deep learning algorithms can be trained on massive sets of medical images, and then evaluate scans faster and potentially better than a human. Or at least that's the hope.

In a review published on March 25 in the British Medical Journal, a team of researchers looked at more than 80 studies over the last 10 years that compared the performance of deep learning algorithms on medical imaging to expert clinicians.

  • They were unimpressed by the studies: Just two were randomized clinical studies — the gold standard for science — and they found that more than two-thirds of reviewed studies were at high risk of bias.
  • Despite those methodology problems, some three-quarters of the studies purported to find that AI was comparable to or better than human clinicians at the work of interpreting medical imaging, which helps fuel the hype.

The bottom line: Just as doctors take the Hippocratic Oath, we need to ensure that AI will do no harm before it becomes an integral part of medicine.

5. Worthy of your time

Rats are us (Kristin Andrews and Susana Monsó — Aeon)

  • A thought-provoking take on why the rats that scientists depend on for lab research deserve our care and empathy.

The low-carbon crisis (Michael Liebreich — Bloomberg New Energy Finance)

  • A comprehensive explanation of how the COVID-19 crisis will change how we use energy, travel, educate and more.

The Postal Service's surprising role in surviving doomsday (Garrett Graff — Wired)

  • It turns out there are plans to ensure that your friendly neighborhood mail carrier will be the one to deliver lifesaving medicines in the event of a biological catastrophe.

How California's largest community college district is making the switch to online learning (Mikhail Zinshteyn — The 74 Million)

  • The focus often goes to elite schools, but community colleges are a major force for social mobility, and they'll need to handle the sudden change to remote teaching.
6. 1 Tudor thing: "Wolf Hall"

Spoiler alert: This marriage will not end well. Photo: Ed Miller/Playground & Company Pictures for Masterpiece, via BBC

Since we'll be home for the durationit's not going to be Easter — this newsletter is recommending pop culture that jells with the themes of Future.

  • This week's edition: "Wolf Hall," the 2015 BBC adaptation of the first two books in Hilary Mantel's trilogy about the power behind King Henry VIII's, Thomas Cromwell.

Why you should watch it: Admittedly you need to squint pretty hard to see the connection between Axios Future and a stately TV drama about the machinations of the 16th century Tudor court in England. But the connections are there!

Cromwell, as imagined by Mantel and brought to life by the peerless English actor Mark Rylance, is the quintessential man ahead of his time, bringing religious reformation and a more effective state to an England just barely out of medieval times.

  • The drama of "Wolf Hall" revolves around Henry's desperate need for a wife who can bear him a son and heir — which is a problem because all of his children keep dying in infancy. It's just another example of how infection put its stamp on human history.

The bottom line: The acting is as amazing as the costumes — Rylance is brilliant, Damian Lewis is a modern celebrity in Tudor times as an insecure Henry, and Claire Foy warms up for her title role in "The Crown" as a somewhat less beloved queen in Anne Boleyn.