The Age of Plagues

It wasn't that long ago that medicine declared a victory over infectious disease. Now a raft of new and mutating bugs are at the door, and a declining public health system is in no shape to fight them.

The man--we'll call him Terry-- was 28 years old and lived in a small Minnesota town. He had a job, a car, perhaps a girlfriend; the record is silent about most of his life. What it does say is that one day in October, he began feeling nauseous. Eventually he went to his mother's house. He had thrown up and was running a fever. She went to work on her third-shift job. When she came home she found her son passed out under the coffee table. He was taken to the emergency room at the nearest hospital, where he was placed on a respirator and given fluids. His liver, kidneys, and lungs were all failing. Within a few hours, he was dead.

When the pathologists cut Terry up--standard procedure when an otherwise healthy person suddenly drops dead--they found little out of the ordinary, except some tiny anomalies around his heart. They were signs, along with his fever and nausea, that he'd had some kind of infection. But to this day no one knows what it was, and it's possible that no one ever will. The doctors who treated Terry didn't think of saving standard lab specimens--blood, throat washes, stool. By the time Mike Osterholm's office called, all the hospital had to offer was a little bit of tissue. It now sits in a vial in a freezer, waiting to be analyzed someday.

Osterholm's official title is state epidemiologist, and his job description involves tracking any disease that pops up with higher-than-expected frequency. Over the years, he's tackled outbreaks of hepatitis and measles, pneumonia and the flu; back in 1981, he was part of the first major meeting at the Centers for Disease Control that discussed a mysterious new condition then called "gay-related immune disease." His team at the Minnesota Department of Health was among the first to identify toxic shock syndrome and Lyme disease. They've carved out a national reputation as one of the best groups of microbe-hunters in the country.

Studying deaths like Terry's is a recent addition to the team's job. Only a few months ago, they likely never would have heard about it; a few years ago, they might not have thought much of it if they had. Infectious disease was a medical specialty thought to be on its way out. The people who got into it were considered to have a slightly anachronistic penchant for what Osterholm calls "a kind of Sherlock Holmes-type work." When he started, there were six people working in the state Department of Health's acute disease epidemiology section, including clerical aides and grad students.

Now, as everyone who's heard of Outbreak and The Hot Zone knows, the bugs are back. In movies and bestsellers, they star as exotic monsters invading from distant locales. The reality, for the most part, is more prosaic and closer to home. But it's not a bit less scary.

There are now 30 people in Osterholm's group, including doctors, microbiologists, and specialists in genetic testing. They don't have space suits, helicopters, and large incendiary devices; their labs, up in a nondescript building near the University of Minnesota, look like glorified high school science rooms. The only odd detail are wire baskets filled with petri dishes where dark smudges grow on translucent liquid. Yellow Post-its identify the contents as salmonella, e. coli, shigella, and "Other." A couple of refrigerators have biohazard symbols on them; another says "food only."

In the office wing a few corridors over, Osterholm can barely keep up a 20-minute conversation without interruption. "I'm sorry," he says as he picks up another call. "We're in the middle of an outbreak." A few dozen cases of salmonella, it turns out, centered around a restaurant; there's at least one of those every week. Earlier in the day, the department has also been notified that a local hospital has found a new kind of wound infection. There's a report on the first confirmed case of this year's flu, a few hepatitis cases, and another foodborne outbreak.

"There really isn't a need to go to the public about any of this," Osterholm says. "One of the things we try very hard to do is to never cry wolf. When you hear us talk about emerging infections, we're very careful so that we don't overwhelm people with what's really there. Because they'll say 'this can't be true.'"

Minnesota got a hint of "what's really there" this year, during a five-month period that began with a meningitis epidemic in Mankato, yielded an outbreak of "flesh-eating" Group A strep near Rochester, and witnessed two simultaneous outbreaks of the pneumonia-like Legionnaires' disease in Mankato and Luverne. All three fell into what medicine has come to call "emerging infections"--bugs that were unknown until recently, or old diseases behaving in odd new ways. Together the four headline-making outbreaks killed seven people; 20 more have died of invasive strep alone since then without attracting much notice.

But the scary thing--the one Osterholm fears overwhelming people with--isn't the bugs, and their apparent resurgence. It's the fact that epidemiology groups like his own are increasingly scarce. That insurance companies pay for fewer and fewer tests, and more and more people never get to see a doctor. That between funding cuts, poverty, and the health care crisis, the entire system set up
to prevent infectious disease is ripping at
the seams.

The wakeup call came in the early 1980s, when doctors started trading news of an odd condition that was killing healthy young men in New York and San Francisco. By the time anyone realized what was going on, AIDS was out of hand. It took another few years for a few scientists to warn that there might be more epidemics where this one came from.

At first much of the talk was about "tropical diseases" jumping from rainforest monkeys and transported by jet plane; that's the scenario of Outbreak and the main fantasy underlying the current fascination with monster bugs. (A computer technician in California has created a home page for aficionados of the deadly hemorrhagic-fever virus Ebola. He reports tens of thousands of hits so far, and has recently upgraded to make an "Outbreak" site with hyperlinks to documents from all over the world (http://ichiban.objarts.com/outbreak-unreg/index.html).

Then microbiologists took HIV under the microscope, and found that it--at least the strain predominant in the United States and Western Europe--didn't really look much like the monkey viruses from which it was suspected to have come. It was, at the very least, a new mutant. This gave rise to another wave of worry. Most bugs are prone to rearranging their genes; some viruses, like influenza, shape-shift so often a new vaccine has to be concocted every year. So any day, somewhere in the world, an old bug might take on a threatening new form. Influenza, after all, killed between 20 and 40 million in 1918, when a particularly aggressive strain emerged from the mutation soup. Most scientists think the planet is due for another deadly flu epidemic before the end of the century.

It wasn't until recently that a third possibility entered the emerging-infections picture. There is now evidence that HIV may have been around as a human infection for at least several decades. But it never caused an epidemic until the 1970s, when growing numbers of people found themselves crowded together in cities where drugs and prostitution skyrocketed. Perhaps, many scientists now say, the main worry shouldn't be about new bugs, but old ones for which humans are rolling out the red carpet.

No one may ever know which of the three scenarios is the most likely; for that matter, focusing on where the bug came from may mean missing HIV's bigger lessons. No one saw it coming; few took it seriously when it arrived; and over time, what once would have been a horror scenario became a fact of life. "We now have infection rates that are five, 10 times as high as when we were almost panic-stricken as a nation," Osterholm reminds his audience at Bloomington's Decathlon Club. AIDS--not gunshots or cancer--is the leading cause of death among American men 25 to 44. It's killed more than a quarter-million people in the U.S., and in some African and Southeast Asian countries, the HIV infection rate is close to 50 percent. No one even dares to think about what will happen once all those now infected actually get AIDS.

Osterholm knows that, as usual when he brings up these stats, his listeners won't flinch. People may shift in their chairs, raise eyebrows. But in the end, they rest relatively assured in the knowledge that with luck and a few precautions, AIDS will be someone else's disease. He brings up the next slide. "I guarantee you," he says, "that by the time this is over, you will know an emerging infection personally."

As his listeners nibble at dessert, Osterholm points to a picture of a purple football helmet. Back in 1988, he recounts, the Minnesota Vikings went to Miami to get the shit kicked out of them; when they came back, their intestines were still acting up. Eventually the team doctor put in a call to the health department, and the players were found to have shigellosis, one of the oldest diarrheal diseases known to humanity. They'd gotten it not playing football, but eating sandwiches on a Northwest Airlines flight.

The sandwiches, it turned out, were prepared by a large commercial caterer that brought in busloads of temp laborers each morning. Eventually the epidemiologists tracked some of them down. "One woman was crying when we interviewed her," Osterholm says. "She told us that she had been working two shifts every day for two weeks with a bad case of diarrhea because she couldn't pay the rent otherwise for herself and the kids. Of course she had no health insurance. And had this not happened among the football players, we might never have found out about it."

It's impossible to tell how many people got shigellosis from those sandwiches. Osterholm's team guesses it's close to 2000; they've identified hundreds of flights that probably served up the bug that fall. Some passengers have since been confirmed as having had the disease, while others were never tested. For that matter, there are probably sandwiches carrying shigella on an airplane, or at a deli counter, or in an office cafeteria near you right now. And if not sandwiches, then perhaps pizza; or cheesecake; or those baby vegetables in plastic wrap.

Foodborne illness has always been a staple of epidemiologists' work, and it used to be relatively simple. Contamination was generally traceable to a particular dish, person, or event--"Grandma's potato salad at the church picnic," as Osterholm likes to put it. Now, chances are that the potato salad came from a deli, which shipped it in from a commercial kitchen. The spuds may be from Idaho, the green onions from Mexico, the mayonnaise from Kansas, and the parsley from Costa Rica. A bug may have hitched a ride on any of them, transferred from soil or water or the mostly impoverished people who harvested, packed, and chopped the food. "Around our department we have a saying," Osterholm cheerfully tells an audience whose forks have stopped clicking. "If you can't grow it in the lab, put it in the salad bar."

As infections go, foodbornes aren't the worst you could have. Most of the time, they resolve themselves after a few days of purging from every orifice (though in people with weak immune systems the results can be more devastating). But what they generally lack in deadliness they make up in frequency. Between 1979 and 1993, the Minnesota Department of Health confirmed 200 outbreaks of foodborne illness. Many more probably went undetected.

This story, with variations, plays out everywhere as bugs turn industrial technology to their advantage. Airborne microbes circulate over and over again in office buildings and airplanes. Cooling towers--along with shower heads, vegetable misters, and just about anything that stays dark and moist--can harbor legionella, the bug that causes Legionnaires' disease. And in 1993, 400,000 people got sick in Milwaukee after drinking tap water contaminated with cryptosporidium, a tiny parasite that causes diarrhea and can kill people with compromised immune systems. Elsewhere, tap water has been found to cause outbreaks of shigella, gaillardia, and hepatitis A.

Bigger parasites--rats, mice, mosquitoes--also have held up surprisingly well. In 1994, the medical establishment got its second major wakeup call when four previously healthy young people dropped dead in the Four Corners area of New Mexico. Their disease was eventually identified as being caused by hantavirus, a rodent-borne bug that has since been found to be common in mice and rats from coast to coast; there's now speculation that hanta infection from rodent-infested housing is one of the factors in the high incidence of kidney failure among African Americans. Similarly, over the last 10 years the United States has seen a gradual spread in the populations of two kinds of mosquitoes--Aedes aegypti and Aedes albopictus, the latter also known as the tiger mosquito--that can carry yellow fever and dengue. Dengue's most serious manifestation can lead to death by internal bleeding; outbreaks have been spotted in Central America and the border states, and many scientists consider it a good candidate for the next American epidemic.

The list goes on. Respiratory and middle-ear infections now break out in daycare centers with such frequency that "you open the refrigerator, and half of it is food, half is antibiotics," Osterholm notes. Malaria, once common in the U.S., is making a return in the South and Southwest. A case of Lassa hemorrhagic fever popped up in a Chicago suburb in 1989. And that's not to mention diseases you wouldn't think of as infections. A growing number of liver and cervical cancers are now considered to be caused by viruses. Sexually transmitted diseases are thought to be the major cause of infertility. Chronic fatigue, according to some researchers, may be an old, but reemerging infection.

"These are not the kinds of things that get solved with one outbreak investigation," Osterholm concludes to a room where you can now hear a pin drop. "These are long-term, forever kinds of problems."

In January 1992, a man walked into a south Minneapolis bar. It may have been any day of the week; he spent most of his time in the place. For a few weeks he'd been sick--coughing, feeling feverish, having trouble breathing. He didn't have a home and hadn't been to see a doctor in a while. Perhaps he thought he had a cold. Perhaps he didn't care to wait in the emergency room for hours.

By the time the man did make it to the ER, he had lost more than 70 pounds. He couldn't walk without help and was coughing up blood; he had chills and felt nauseous much of the time. The doctors tested him for tuberculosis, got a positive, and put him on antibiotics. Eventually he recovered. Over the next few months, something like 41 people who had hung out with him in that bar tested positive for TB; the case was written up in the New England Journal of Medicine as the first bar-centered TB outbreak ever recorded.

TB is one of those diseases that was thought pretty well conquered two decades ago. Sanitariums, to which "consumption" patients had been sent to breathe fresh air and stay away from other people, were closed; antibiotics could take care of the problem more cheaply and comfortably. But as early as the 1970s, some doctors in New York noticed that TB was returning, especially among homeless men and drug users. The numbers rocketed through the 1980s as the city's shelters filled to overflowing; one person could cough on dozens of others all night long, and give them all the disease. People with AIDS, who were often also homeless, were especially vulnerable to the infection.

As with AIDS, it took years for TB to be recognized as a serious problem. Today, both are seen as "urban diseases," disproportionately afflicting the poor and people of color. In addition to homeless shelters, prisons and dormitories provide ideal conditions for TB's spread. By 1991, almost $700 million was spent nationwide on an epidemic centered on the East Coast, but reaching all the way across the continent. Minnesota officials report about 140 new TB cases each year.

TB, though potentially lethal, is entirely treatable with antibiotics. Thus, for a long time docs simply gave their patients bottles of pills and told them to take this twice a day, this three times, and come back every other day for a shot. Many patients--illiterate, too poor to afford bus fare, or simply too busy surviving--didn't complete treatment, got sick again, and went on to infect more people.

And along the way something else happened. After being exposed to antibiotics for a while, the TB bacteria began to mutate; strains that could elude the chemicals had a better chance of survival. If treatment was completed, the bugs not killed by one antibiotic would usually succumb to another. But if patients didn't take all the meds, resistant strains multiplied. The next infection was that much harder to treat. After a while, bacteria emerged that could resist several classes of antibiotics. By 1992, around 8 percent of new TB cases around the country were multiple-drug resistant, as were almost one in four relapsing cases. So far, no TB strains have been seen that resist all known drugs, but many researchers say the clock is ticking.

In the decades since World War II, doctors have been throwing antibiotics at everything but the kitchen sink. Patients who asked could get them for a cold; some people were given the meds simply as a preventive measure. The drugs were also routinely dumped into animals and animal feeds. Even vegetables grown in manure-fertilized fields have been found to contain antibiotics, and bugs resistant to them.

A predictable vicious cycle has ensued. The remaining effective antibiotics are now often prescribed in higher doses and wider combinations, giving bacteria yet more incentive to mutate. Evidence has emerged that bacteria can "learn" from each other, passing pieces of genetic code even across species. And once germs become resistant, even seemingly innocuous infections can turn catastrophic: Older people still remember the days when you needed to carefully watch a cut because if it turned red and swelled, you might have a wound infection that could result in amputation and death.

Ironically, the ultimate bacterial resistance labs are health care settings, especially hospitals, where bugs find a variety of hosts with weakened defenses. The most vulnerable are AIDS, cancer, and transplant patients who are given powerful drugs to suppress their immune systems. They might pick up dozens of infections at one time and then take multiple powerful antibiotics, making them what one researcher calls "human petri dishes."

In 1992, 90 percent of staphylococcus aureus, the bacteria involved in toxic shock syndrome that can also kill surgery patients, were found resistant to penicillin and other antibiotics. Staph infections are common in hospitals, and only one type of antibiotic--vancomycin--reliably works against them any more. But another class of bug, enterococci, are already resistant to that one, and they commonly coexist with staph in the same patient. Earlier this year, scientists for the first time showed vancomycin resistance passed between the bugs in the test tube; it may be only a matter of time for the same thing to happen in humans.

At Hennepin County, says infection-control coordinator Dr. Margaret Simpson, "we've so far been lucky" not to see vancomycin-resistant enterococci. The hospital does have staph aureus infections, and about 10 percent of them are multiple-drug resistant; Simpson says at some metro-area hospitals the rates are much higher. All area hospitals have had to come up with new infection-control measures; some patients with highly contagious infections are put in "respiratory isolation" rooms which don't vent to the rest of the hospital, and where caregivers go with specially fitted "Darth-Vader-type" masks. "We go through waves of fear occasionally," Simpson says, "when we realize that this is becoming a reality. When I was trained, most of these diseases were nonexistent or could be treated. People of my generation now have had to work through that and decide if they want to continue being a health care worker."

Bacteria aren't the only bugs developing resistance to what were once thought the ultimate weapons against them. HIV can mutate so fast that a patient's infection will split off resistant strains almost as soon as an antiviral medication is given. Tiny parasites that live in drinking water have learned to evade chlorination. Even bugs in the literal sense can develop resistance; there are strains of mosquitoes that are unbothered by various pesticides.

New discoveries are unlikely to come to the rescue. After 50 years of mining evolution for the chemicals microbes deploy against each other, science has found all the easy ones, and researchers say new antimicrobial drugs will be few and far between. Last year, only two were approved by the FDA; both targeted HIV. "There's nothing on the shelf," one bacteriologist told reporters last year, talking about resistant staphylococcus. "Nothing on the pipeline. If we lose vancomycin, we're going to be back to the 1930s."

"My parents grew up before the antibiotic era," is how Osterholm puts it. "I have lived in the antibiotic era. And my children--any children born now--will be living in the post-antibiotic era."

Russell and John (not their real names) are tearing through the corridors in the Hennepin County Community Services building like extremely healthy 4- and 7-year-olds. They bypass the big toy basket and head straight for the nurse's desk, where they pick candy out of a bag she keeps in the drawer. Back in the waiting room, their mother listens to Dr. Linda Hedemark explain the treatment regime.

Both kids have to take several types of antibiotics a day for several months, and the youngest has a problem keeping his meds down. The mother has tried squirting the liquid into his throat with a syringe, mixing it into his baby bottle, and finally feeding him through a tube. Nothing has worked too well. There are also problems with the way the medications are mixed at different pharmacies; it's not easy to keep all the dosages straight.

The kids have tuberculosis, and they were "very, very sick" when they first came in, Hedemark says. The youngest was hospitalized right away, and the county team has been staying in close touch with the family ever since. They do this for about 80 people every year, some of them in worse shape than Russell and John. Often outreach workers go looking on the streets for patients who haven't been showing up. Sometimes they help them get housing, food, bus tokens, chemical-dependency treatment. Occasionally they need to find translators; some 50 percent of the county's TB patients are foreign-born.

This clinic is a rare thing. Most general hospitals around the country can't even keep track of patients as they pour into the emergency room, much less follow up on individual cases, let alone help with needs other than direct medical care--even when that would help avoid the next emergency-room visit. And even here, this kind of close-up care is available only to TB patients, whose disease has received special funding attention from Congress.

The resource crunch applies to most of the things that, according to health professionals, could prevent a lot of the basic infections. Vaccinations must reach at least 80 percent of a population to prevent epidemics; in some Minneapolis and St. Paul neighborhoods fewer than 25 percent of preschoolers get the recommended childhood shots. Regular medical checkups are unavailable for lots of people who are uninsured or underinsured; thus diseases, as in the case of the Minneapolis bar patron, often aren't spotted until they're full-blown and have been passed on to others. And some epidemiologists are starting to worry that managed care, with its emphasis on cutting costs and "unnecessary" tests, may be missing many infectious agents.

Though the poor are generally the first to fall through the health care cracks, microbes are one social scourge not even the rich can get away from. In California, certain outbreaks have been reported among wealthy homeowners who caught bugs from their domestics. And in woodsy Twin Cities suburbs like North Oaks, researchers follow Lyme disease as it makes its way from deer ticks to humans on the five-acre lots.

Infection, in other words, is the most public of all health problems. Bugs shrug off boundaries of class, race, culture; they cross city lines, national frontiers, and oceans. And the only way to spot, let alone treat or prevent outbreaks, is through a system that reaches as many people as possible--public health. The bad news is that that system is pretty well in shambles.

Two months ago, a government research group convened by the State Department released a report on "emerging and re-emerging infectious diseases." The report was couched in the usual subdued language, but between the lines you could spot the bureaucratic equivalent of desperation. The cover featured a map of 17 major global outbreaks in the 1990s: Diphtheria in the former Soviet Union. Lassa and Ebola in Africa, dengue in Australia. An aggressive, continent-spanning cholera that reached Latin America in 1991 and has since been found in the U.S. border regions. And those, the report's text warned, were just the outbreaks that got noticed.

"At the present time there is no government agency or group that has the mandate, the flexibility, or the funds necessary to respond to infectious disease emergencies," the document said. "[Officials and doctors] scramble to find resources and solutions on an ad-hoc basis. Response is made even more difficult by the occasional occurrence of widespread shortages of drugs, vaccines, and antisera." (Drug companies have little incentive to make vast quantities of drugs for people who may or may not be able to pay.) "Moreover, there is virtually no surge capacity for producing many of the unique medical supplies needed on an emergency basis."

And finally, "the component of the public health system that protects the public from infectious microbes has been neglected both here and abroad. Federal, state, and local efforts to control communicable diseases are concentrated on a few targeted illnesses [AIDS, cancer, and other diseases that have advocacy groups], with few resources allocated to address new or re-emerging diseases. This limits the ability of the U.S. medical community to detect and respond to outbreaks."

To wit: In Milwaukee, the cryptosporidium outbreak that made 400,000 sick was only spotted when stores found themselves running out of toilet paper and diarrhea meds. In Nevada, an outbreak of e. coli from fast-food hamburgers that eventually killed four children wasn't found until it spread to Washington. The 1989 Lassa patient in Chicago was sick for weeks before doctors even diagnosed him; it was sheer luck that no one else got infected.

Three years ago, Osterholm conducted a study of disease surveillance capacity around the country, finding that government spent $74 million on tracking all infectious diseases in 1992. Of that, $42 million came from the federal government. By contrast, the Pentagon spends some $225 million each year on military bands.

What's more, 95 percent of the federal money was earmarked for just four areas: HIV, tuberculosis, sexually transmitted and vaccine-preventable diseases. All the rest--emerging microbes, food-and waterborne diseases, drug-resistant organisms, everything--received $1.5 million in federal surveillance funding. "That's like trying to run O'Hare International Airport with tin cans and string," Osterholm told a U.S. Senate committee in September. In 12 states and territories, there was not a single person responsible for tracking food-and-waterborne diseases, he added. "You could sink the Titanic in their backyard, and they would never notice."

"There has been a complacency that has developed over last 20, 25 years," says James Hughes, director of the National Center for Infectious Diseases at the Centers for Disease Control. "You happen to be living in an area under purview of a state health department that takes infectious diseases very seriously and has the capacity to identify and respond to many of the problems. But that's somewhat unique."

Hughes's, of course, is the agency that's supposed to pick up where everyone else may fail, deploying superior technology and unrivaled expertise in the worldwide battle against the bugs. But, Hughes admits, "we have had some severe staff shortages, and there's currently some fiscal uncertainty." More plainly put, the CDC is emaciated. Just two years ago, when it was renamed the Centers for Disease Control and Prevention, added responsibilities without added funding resulted in cuts of 518 non-prevention jobs. Current funding, agency officials say, is insufficient even for basic surveillance, not to mention responding to crises.

When plague appeared in India in 1994--a potentially massive global health threat--CDC closed down all of its Lyme disease research to free up some scientists. When leptosporidiosis surfaced in Central America this summer, a retired researcher was sent to investigate it. And when Ebola struck Zaire in May, the CDC sent a team composed of a mid-level Ph.D., a postdoctoral student, and a visiting scientist; on arrival in Kinshasa they found they didn't even have the money to rent bicycles. Samples of Ebola-contaminated blood were shipped to Atlanta via Federal Express. CDC's Biosafety Level 4 lab, one of only two in the country deemed safe enough to tackle "hot" bugs, is deteriorating; the agency finally got the OK for $47 million to construct a new one, but that was whacked by Senate budgeteers this fall.

The story repeats itself wherever you look. The U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), star of Richard Preston's The Hot Zone, expects its budget by 1997 to be cut to two-thirds its 1991 level, and to lose more than 120 of its 600-plus scientists. The World Health Organization's total budget is less than what New York City spends each year for street cleaning. For its emergency viral-outbreak response program, WHO had a robust $25,000 to spend in 1993.

On a more pedestrian level, funds for food and water safety have dwindled steadily through the past decade, partly as a favor to industry and partly to save money. The budget just passed by Congress includes massive new reductions in water and sewage treatment funds. By some estimates, Minnesota alone stands to lose $6.7 million in revolving EPA funds alone. "If [waterborne] bugs were watching C-Span," says one local public health official who doesn't want his name used, "they'd be cheering right now."

In 1992, the CDC announced what it said was a bare-bones prevention strategy to help spot emerging and reemerging infections. The full program would have cost $200 to $500 million a year; of the $125 million the agency actually asked for, Congress approved $7 million. With that money, the CDC has started a much pared-down pilot program involving four state health departments; Minnesota's, with a grant of $350,000, is one of them. Among the projects is what the researchers fondly refer to as "the death study"--the survey of unexplained deaths that turned up Terry and about 100 other healthy Minnesotans between 1 and 49 years old who apparently died of unidentifiable infections.

Minnesota was picked as one of the participants in the study because, compared to most, its epidemiology department is in good shape. Osterholm's team has built a web of connections with public and private researchers around the state, from the Mayo Clinic to the University of Minnesota. (Last month it was announced that the state and the U were collaborating in a new international virology center with a focus on emerging infections.) The group has also been adept at augmenting its $2.4 million budget--of which about one-fifth comes from the state--with research grants and special projects; Osterholm maintains they're the first in the world to use "genetic fingerprinting" tools on a broad disease surveillance scale.

And still, he says, there's nowhere near enough. Triage is standard practice, he says, as the department chooses which of the potentially threatening leads it receives will be followed up on. Federal funding is projected to stagnate through 1997; salaries for the researchers are way below what they would be in the private sector. The department's freezers are holding thousands of vials of blood from newborns, waiting for the CDC to resume funding for an HIV screening program; if cutbacks continue at the present level, Osterholm says, "we're not even going to be able to tell you in a meaningful way what's going on with AIDS in this state. We feel as if we're in societal quicksand much of the time."

It's a fairly safe bet that funding to tackle emerging infections won't reach a level that public health officials deem adequate anytime soon. Even if it does--if, say, there's a particularly mediagenic plague that forces policy makers into action--it won't be enough. Epidemiologists may be able to spot diseases sooner rather than later, which would have benefits: Finding the Schwan's salmonella outbreak even a week earlier, Osterholm says, would have saved millions in health expenditures. Still, epidemiology's work by nature is after-the-fact. They can do very little, except issue warnings, about the reasons why bugs emerge in the first place.

There are two main culprits: poverty and environmental destruction. Already, close to half the world's population lives in a couple dozen "megacities" with populations of more than 10 million each. Most of them are in the Third World, but they also include Tokyo, New York, and Los Angeles. Slums of some description make up an ever greater share of these cities; the people who live in them lack decent nutrition (which in itself staves off many of the basic infections), housing, or health care. Of the halfway lucrative jobs, many are in drugs and prostitution. Open sewers, common in Third World cities, can make one person's waste the next person's drinking water. And in New York City, reports of rat bites to humans went up 70 percent between 1992 and 1993. (The city's rat-control budget continued to be slashed during the same period.)

On the environmental score, scientists have long pointed out that they have no clue what exactly lives in the forests of the world. There's some evidence that bugs that so far have bothered only deep-woods creatures are making the jump to humans as urban sprawl, mining and oil drilling encroach on their habitat. Global warming is one of the suspected causes of massive algae "blooms" on the world's oceans, offering parasites unprecedented options. (Contaminated algae, picked up in the bilges of ships, are thought to have brought the current so-called Seventh Pandemic of cholera to South America.) And insects and other disease "vectors" change their habits when the climate shifts: The mosquitoes that carry dengue and yellow fever have been slowly expanding their range throughout the southern and central U.S. They are not "in Minneapolis right now," Notre Dame entomologist George Craig told the Los Angeles Times in 1991, "and the reason is temperature. Will [they] go to Minneapolis if global warming occurs? The answer is yes."

"The survival of the human species is not a preordained evolutionary program," writes Joshua Lederberg, a Nobel laureate and one of the most prominent prophets of emerging infections. "We have beaten out virtually every other species to the point where we may now talk about protecting our former predators. But we're not alone at the top of the food chain."

Or, as science writer Laurie Garrett puts it, "humanity will have to change its perspective on its place in earth's ecology if the species hopes to survive." People will never win the "war" on microbes, she suggests; the metaphor itself is useless, suggesting a malevolent enemy that can be wiped out with just the right weapon. The best hope is not to conquer the microbes--witness the short history of antibiotic euphoria--but to avoid fatally tilting the balance. "It's either that," Garrett concludes, "or we brace ourselves for the coming plague."

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