If Swine Flu Happens During COVID-19, Are We Screwed?

It feels like 2020 can’t get any worse, but it always does. Genetic testing of pigs in China from 2011 to 2018 leads us to consider a truly dire possibility: What if we weren’t just dealing with one historic and deadly pandemic, but two? Could it even happen?

There’s an outbreak of H1N1, or the “swine flu”, running through China’s pig farms right now. According to a study in the Proceedings of the National Academy of Sciences, recent genetic testing of pigs in Chinese farms show genes “similar to [swine flu ‘09] virus,” and has “all the essential hallmarks of a candidate pandemic virus.”

So, how worried should one be about a second pandemic-within-a-pandemic?

As it so happens, the flu is more infectious than even COVID-19, but the world is also better prepared to battle it. It’s been doing so for more than 100 years, after the 1918 pandemic ravaged a world that hadn’t yet discovered flu viruses. And the world, if not the U.S., is already at heightened alert for infectious disease. It’d be hard, but not impossible, for two pandemics to run through the world’s population at the same time.

Early warning signals are working

Despite what you may have heard, COVID-19 is not the flu. And the fact that we even know about the possibility of a swine flu outbreak is because experts know all about influenza and take it incredibly seriously. That we are discussing a possible pathogen as it is being reported in academic journals is a good sign. In many ways, health experts are playing catch-up when it comes to Covid-19.

“So what we’re seeing a little bit is what public health is constantly doing,” Theresa MacPhail,a medical anthropologist andAssistant Professor at Stevens Institute of Technology, told Motherboard over the phone. MacPhail was in Hong Kong in 2009 during a previous outbreak of H1N1 and worked with the CDC to contain it.

The World Health Organization runs the Global Influenza Surveillance and Response System. (GISRS) Established in 1952, GISRS constantly monitors influenza hotspots and coordinates with healthcare providers and world governments to keep things in check.

“In China, [government officials] regularly sample birds on duck and chicken farms and pigs on pig farms and all the workers who work there for this reason: to see what strains are in circulation to see if there are any potential problems,” MacPhail said. “So that’s what you’re seeing is this particular strain has been in circulation for a while.”

According to MacPhail, there’s good cause to worry, but not to panic, yet. China’s experts sounding the alarm this early is a sign that the system is working as intended. She also said these kinds of alerts and alarms happen all the time. “Most of the time that stuff is ignored by the public,” she said. “You don’t know that this is normal.”

Katherine Mason, a medical anthropologist and an assistant professor at Brown University, said that the world is prepared for the flu in a way it wasn’t for the coronavirus. “Everyone always thought the next pandemic was going to be an influenza pandemic,” she told VICE on the phone. “Every year you get news of some new strain of flu … [scientists] have spent a lot of time and resources trying to be able to anticipate the flu, which is partly why Covid-19 caught people off guard.”

Nidia Trovao, a virologist at the National Institute of Health, said she’s watching the new H1N1 strain but isn’t particularly worried about it. “I think the probability of having two pandemics simultaneously is really really low,” she told VICE over the phone. She said that the virus has made the jump from human to pig, but only in the workers in close proximity to the swine. It has yet to move from human to human. “The big evolutionary hurdle is for the virus to gain the capacity for human to human transmission.”

Flu is watched so closely because, in the past, it’s been devastating. The 1918 flu pandemic was a predecessor of H1N1. While it’s often called “the Spanish Flu,” epidemiologists traced its origins to pig farms in Kansas, where it spread through U.S. Army bases and into the wider world. Epidemiologist and historians estimate that the flu killed more than 50 million people worldwide. It was devastating, but scientists learned a lot about how to fight a global influenza pandemic.

The concept of social distancing and wearing masks to prevent the spread of infection were lessons learned during the 1918 pandemic. One of the reasons that the flu spread so fast was because of the close quarters assigned to troops in the U.S. military. Much of the world’s modern health system and America’s modern mliitary’s sanitation practices are direct results of what we learned during the 1918 pandemic.

“This is actually a system that’s working that’s been in place for a long time,” MacPhail said. “And scientists are relatively on top of it.”

Health measures are already in place

According to MacPhail, the world is better positioned to deal with a flu outbreak than any other infectious disease, even Covid-19. “In some ways, this is the best possible time that’s ever been for a new dangerous flu, and this one isn’t even that dangerous. It looks like the cases in people are pretty mild,” she said.

She acknowledged that the flu mutates all the time. What seems mild one day may yet turn deadly. But the world is already at least familiar with the measures it needs to take to avoid mass infection. They look a lot like what the world (except much of America) is already doing: masks, shutdowns, social distancing.

“But, say we do have something terrible,” MacPhail said. “We’re already wearing masks…we’re more prepared than we’ve ever been for something like this.”

The GISRS meets twice a year in Geneva to create the seasonal flu vaccines. “This works by having more than 100 laboratires around the world that get samples from these patients with influenza-like illness, then they test for flu using different methods,” Trovao said. “The good thing here is that countries in the Southern hemisphere are currently facing their flu season so we can learn a lot from their experience. We’re seeing lower levels than we usually observe this time of the year. Of more than 2,000 sample tests, only 37 were positive for flu. Those are good results.”

But Trovao those good results should be interpreted with caution. “The pandemic crisis forced us into isolation which will naturally curb transmission,” she said. She also noted that there have been some reports of people getting both the flu and Covid-19 at the same time. “Clinicians should be alert that the positive test for either virus does not rule out the possibility for the other.”

Flu is more transmissible and it evolves more quickly, but the period between contracting the virus and showing symptoms is much lower than Covid-19. We also have vaccines for the flu and systems in place to develop new ones quickly when a new strain appears. According to MacPhail, a new flu vaccine takes roughly 9 months after experts identify a strain. More than 130 separate Covid-19 vaccines are in development currently. The world is spending billions to rush one to market and best estimates say it won’t be available until early next year.

“We were not prepared for Coronavirus in the same way,” MacPhail said. “We weren’t really surveying Coronavirus the way that we do flu and we don’t have the vaccine technology in place already for something like Coronavirus. So that’s what we’re seeing right now and why this is so bad.”

H1N1 isn’t the only influenza strain on the watchlist. Experts are constantly tracking outbreaks across the globe. “Every day there’s something,” MacPhail said. “Normal people don’t know that there’s a botulism outbreak in cheese in Ireland right now.”

There’s also an ebola outbreak in the Democratic Republic of Congo, cases of bubonic plague in Mongolia, and yellow fever in Ethiopia.

The point is: the world is filled with disease. A new one popping up isn’t cause for panic, especially when it’s being so closely watched, but it is an opportunity to be vigilant.

But what if it’s bad?

These assurances are good reminders of the world’s robust public health system, but they’re cold comfort in the U.S. where COVID-19 infections and deaths rise daily.

In America, and to a lesser extent elsewhere, COVID-19 isn’t just a public health issue, it’s a fiercely political one. State and local officials push back against CDC recommendations, citing economic concerns. Anti-maskers make public scenes that are quickly posted online and go viral. In my own neighborhood message board here in South Carolina, anti-maskers are boasting that they won’t wear a mask under any circumstances. A U.S. passport, once the key to unlocking a world of travel, is now a scarlet letter. So many countries are turning Americans away that it’s easier to list the countries Americans can still travel to than those that block them.

MacPhail initially didn’t think COVID-19 would be that bad, but told VICE after it became a pandemic that she’d been wrong. According to MacPhail, she failed to predict that the U.S. Government would do such a horrible job containing it.

It’s possible, and even likely, that a new round of restrictions based on a new outbreak wouldn’t be enough to convince people to change their opinions on masks and social distancing. They might even double down, at least at first.

Mason said she worries that fighting a second pandemic would be hard, in part, because the flu and COVID-19 have such similar symptoms. “If Covid continues to rage the way it has been here in the states, it’s gonna be very difficult to separate out the appearance of a new flu strain. That’s what I’m worried about.”

Winter is coming, and winter always brings the flu and other respiratory diseases. “I have two kids,” Mason said. “My kids, in the winter, pretty much always have a virus for like four or five months. So it’s going to be hard to differentiate a new one from the one we already have. That’s number one. Number two is the capacity to deal with it which is non existent in the United States at the moment. If the flu started going around, I would be surprised if it made things better rather than worse.”

According to Trovao, the scientific community is already worrying about the flu season. “By itself it already causes high morbidity and mortality,” she said. “I think this is the year where we encourage people even more strongly to get the flu shot, because it lessens the burden on the healthcare system so those beds and capabilities can be directed towards the pandemic.”

“What we are doing to curtail Covid-19, might also curtail the spread of other viruses and reduce transmission of both viruses,” Trovao said. “That’s where we need to focus—keeping people wearing masks and continuing to physically distance and getting the vaccine that we produce every year.”

Anyone can catch COVID-19, but the rates of infection and death are highest among the people at the margins of American society—the elderly and members of racial and ethnic minority groups in particular. This may make it easy for the powerful and privileged to ignore it, and even demand that others risk their lives to provide them with goods and services. A flu with a higher death rate than even Covid-19 (which doctors now believe may cause extensive and life-altering complications even after recovery) would not be so easily mentally sidelined even with the buffers of wealth, power, and even youth.

“I just keep thinking, ‘Thank god [the death rate is] only between one and two percent,’” McPhail said. “But that’s shitty, because that allows us to ignore it for longer. I guarantee you, if a bunch of 20 and 30 year olds were dying right now we would be taking this much more seriously. And if it was killing kids, we’d be on top of this.” (Younger people and children do catch Covid-19 and die, but at rates much lower than older people with underlying conditions.)

“The flu strikes children pretty hard usually,” Mason said. She stressed that every flu strain is different, and affects different groups in different ways. “But if it follows the same pattern as most flu outbreaks, we would be seeing a lot more children dying.”

In particular, Mason pointed to people’s reluctance to get flu shots as a reason for its annual death toll. Concerningly, anti-vaccine conspiracies have already begun to circulate regarding a possible Covid-19 vaccine.

“Covid is worse, don’t get me wrong, but the flu is still a big killer every year,” she said. “Part of the reason is people don’t get flu shots even though we have them because they don’t take the flu seriously enough. The flu just spreads like wildfire. If we think Covid spreads easily, if we’re hit with a really serious and deadly flu pandemic it’s going to be even worse.”

According to McPhail, a deadly flu pandemic on top of COVID-19 would be nothing short of a national “reckoning.”

“Coronavirus is playing into our worse national traits whereas flu would make us have a reckoning,” MacPhail said. “This is why, traditionally, we’ve been more afraid of the flu. Because it kills indiscriminately across age groups.”

Mason pointed out that even if there’s not a strain of H1N1, seasonal flu on top of the Covid-19 pandemic in the winter, when people get more respiratory diseases, is still concerning.. “[Winter] is going to be really bad. I’m very very concerned about it. If we throw the flu on top of it, even just seasonal flu… nature doesn’t care whether you’ve had enough. It’s gonna do what it’s gonna do. It can get a lot worse.”

Which is why, thankfully, the world’s health experts and governments do all they can to contain swine flu. The 2009 H1N1 epidemic began in Central Mexico and spread out of control before global health measures, including a vaccine, brought it under control. The newest outbreak is in China, a country taking active measures to contain and control the virus’s spread.

The pandemics of 1918 and 2020 have taught us a valuable lesson, though: the world’s virus response is only as strong as its weakest link, and now as in the past, that weak link is the U.S.