An illustration of two figures standing within an orange pill capsule, surrounded by a storm of black and blue infectious diseases.

A Constellation of Storms: The Threat of Infectious Diseases

Infectious microbes constantly emerge and constantly mutate. To survive, we need extraordinary science and scientists.

By Arturo Casadevall • Illustration by Anna and Elena Balbusso

Infectious disease is the only field of medicine where things keep getting worse.

If I walked into Johns Hopkins Hospital today, I would have fewer options for treatment for bacterial diseases than when I was an infectious disease fellow in the 1980s. Why? Drug resistance. For example, pneumococcus, the bacterium that causes pneumococcal pneumonia, has become penicillin-resistant. Similarly, staphylococcal infections are more resistant, leaving us with very few drugs against them. 

SARS-CoV-2 provides the latest example. The monoclonal antibodies used to treat President Trump when he had COVID-19 just two years ago are useless today. 

This does not happen in other fields of medicine. Cardiac medicines do not lose efficacy with time. If you successfully develop a drug that prevents heart disease, you will never hear that it has suddenly become useless. Aspirin works as well today as when it was introduced in 1899.

Another challenge in infectious diseases: It’s the only field of medicine where new diseases emerge routinely. When they do, there are often no therapies available, leaving humanity defenseless—at least at first. Think about HIV, Ebola, COVID-19. Then, when medicine and science develop drugs and vaccines, the microbes change and defeat them. It’s a never-ending battle. 

We have just completed the 23rd year of the 21st century, and we’ve already seen seven major viral epidemics (SARS, MERS, H1N1, Zika, Ebola, COVID-19, and mpox). As we face these assaults from nature every few years, we’re also losing treatments to drug resistance. And we are not getting new infectious disease drugs because they don’t generate as much revenue for pharma companies as drugs you have to take daily. 

We face a constellation of storms. 

Cancer is not going to take out society. Alzheimer’s is not going to take out society. But an infectious disease could. 

COVID-19 took more than 1 million American lives—more lost than in all this country’s wars combined. That happened with a disease that had less than 1% mortality. What it if had had 5% mortality? Would police have gone to work? Would power have stayed on? I say no. Cancer is not going to take out society. Alzheimer’s is not going to take out society. But an infectious disease could. 

This is the threat. Are we up to the task? Maybe.

I know I don’t sound optimistic, but actually I am. Look at the big trends: fewer people in poverty, lower maternal mortality, longer life expectancy. Major efforts to improve the lot of humanity continue relentlessly. And we learned much from COVID-19. We developed vaccines and drugs against COVID-19 in less than a year. Astounding.

But humans have a major weakness: We don’t have great capacity for long-term planning. As a species, we are really good at dealing with what’s in front of us. When it comes to disaster recovery or emergency medical treatment, we’re adept at using resources and knowledge at hand to help others in crisis. But for long-term crises like climate change? Not so much. 

The fight against infectious disease is a long-term fight, a constant struggle in which humanity needs to invest.

At this point, you probably expect me to demand more funding. It’s true that funding is a problem, but overall society has been generous in supporting science. So I want to address a different weakness: how we use the resources we are given. We can do better science. We can do science based on Rigor, Reproducibility, and Responsibility—the pillars of our R3 Center for Innovation in Science Education

Too much scientific research today is too safe. A recent Nature article showed that the average paper and patent are much less disruptive today than they were just a few decades ago. Safe, small-minded science won’t help us meet the existential challenge of new infectious diseases. We need extraordinary science and scientists. 

By training scientists better in the how and why of basic science, we can have a huge impact on humanity’s ongoing battle against infectious disease. Better-trained scientists (and physicians) mean higher-quality science that increases the chances we will survive as a species. Science is humanity’s best insurance policy. 

Yes, infectious disease is a field where things will get worse, where change is constant, where the war will never be won. We have no choice but to raise the level of our science by constantly working harder and smarter. 

That’s our best hope for staying ahead of the microbes.