infectious disease

Two pandemics: Ghosts of the 1918 outbreak

Recently I’ve been reading a book (published in 2004) by Betty O’Keefe and Ian McDonald titled, Dr Fred and the Spanish Lady. The work examines the experience of Dr. Fred Underhill, who was the senior public health officer in Vancouver during the 1918 pandemic. While there had been a host of influenza pandemics through history, the 1918 pandemic killed perhaps 100 million people globally.

What struck me while reading the work was the manifold similarities between our experience of COVID-19 and that of almost exactly a century before. During our current pandemic some countries, such as Australia, New Zealand and Taiwan, acted quickly to enact travel restrictions. But that was the exception rather than the norm. Similarly, in 1918 troop ships brought influenza to Canada, even though during the crossings the ships would have to repeatedly stop for the burial of sea for returning soldiers (O-Keefe and MacDonald, 30-31). In 1918, travel restrictions were not implemented because everyone in Canada wanted to bring the troops home. While understandable, this was also tragic. During COVID-19 there were no effective limits on returning citizens in the United States, likely because there just was not enough public support for this measure. Of course, there were limits on non-citizens’ travel. But since the SARS-Cov2 virus does not discriminate based on citizenship, those countries that did not limit their citizen’s movement, and quarantine them on arrival, have paid a heavy price. …

HIV/AIDS, an “Introduction to International Studies” class lecture

Mercator Map of the Congo, 1595, from the Northwestern University Library Maps of Africa collection, accessed through Wikipedia.

I wrote a book, the AIDS Pandemic in Latin America, and have studied public policy and infectious disease for nearly twenty years. Here is a lecture that I wrote (around 2010?) for an “Introduction to International Studies” class. It would need to be updated now; it may also some references to my own experiences, which would need to be removed. But my hope is that it might prove a useful starting place for someone who wants to do a lecture on this topic in a similar class.

Shawn Smallman









Character of the Virus:

  • HIV is not one virus but many
  • The result of more than one introduction into humanity
  • Two main forms: HIV-1; HIV-2
  • Great diversity
  • Difficult to create vaccine
  • 10 year latency
  • initial infection- blood/sex/mother daughter
  • flu-like symptoms
  • body holds the virus in check
  • over time, the virus gradually erodes the immune system’s ability to defend the body
  • the person dies of opportunistic infections
  • there are different latency periods for different people: my Cuban experience
  • medicines don’t work with everyone: my experience in the support group in Sao Paulo
  • most people, the medications are effective
  • recently realized: in a discordant couple medications prevent transmission in 98% of cases
  • means that treatment is prevention
  • heart-breaking: long argued that treatment was too expensive
  • the only economical way to treat the virus was prevention
  • proves to have been a flawed paradigm

COVID-19 in Latin America

Flyer for our upcoming presentation

Next Tuesday my department will be having a presentation on Zoom  about COVID-19  in Latin America. During this discussion I’ll be talking about Bolsonaro’s leadership in Brazil, and the current pandemic trends in that country. Dr. Rodriguez will be talking about Argentina’s response, while Dr. Young will be discussing the experience of both Cuba and Mexico. Since I know little about the COVID-19 situation outside of Brazil in Latin America, I am particularly interested to hear what my co-presenters will say. The talk will be 2pm West Coast (US) time. Please RSVP if you are interested in participating.

Shawn Smallman

Fear, Fact and Fiction: COVID-19’s Origins and Spread


Photo by Isabella Mori, who provides this context: In traditional Taiwanese night markets, since people / food stands are in close contacts, most people / vendors wear masks now, in order to protect themselves and others.

I gave a talk yesterday for WorldOregon on COVID-19, and what we know about it’s origins and spread, as compared to conspiracy theories. What you might not know when you watch this is that I wrote a talk before asking how long it should be. So I wound up having a fifty minute talk for a twenty minute delivery. Throughout the whole talk I was trying to summarize. My bad. But I had a good time and enjoyed hearing the questions. Thanks WorldOregon! …

Health care and Cyber-attacks

An Opte Project visualization of routing paths through a portion of the Internet. ( via Wikimedia Commons.

Sadly, one of the most common cyberattacks is upon health care centers, particularly ransom-ware attacks upon hospitals. While digital records and telemedicine are proving essential during the COVID-19 pandemic, hospitals’ reliance upon digital resources also make our health care systems vulnerable to attack. As this article by Jocelinn Kang and Tom Uren says, cyber-defense efforts now need to prioritize our health care systems.

If you are interested in hearing more about global topics, please listen to my podcast, Dispatch 7. You can find it on Spotify here, or by searching whichever podcast platform you prefer.

Shawn Smallman, 2020

Cyber tools for predicting COVID-19’s spread


The Spanish Influenza. Chart showing mortality from the 1918 influenza pandemic in the US and Europe. Wikipedia commons.

The New York Times had a remarkable story yesterday morning by Donald G. McNeil Jr. , which talked about a company (Kinsa) that markets smart thermometers. The company can use the data on fevers from these devices to foretell where the outbreak will grow, before that data shows up in other sources.  You can see the company’s map here. As the NYT article says, there is so much interesting data here.

As someone who has spent a lot of time in Florida (my mother was a mystery writer, who set her novels in the bars of West Florida) I am deeply worried by the data on southeast Florida, as well as around Tampa. And even some of northern Florida, such as Duval county, has high levels of atypical fevers. But what is happening in Michigan? The map around Detroit has not lit up as red as Miami, but there is a swath in the south of the state where the levels of atypical fevers have raised. The swatch stretches as far west in the state as Kent county. I wouldn’t have expected what appears to be happening in Utah county, and Salt Lake county, Utah. But these counties still do not light up as much as Broward, Palm Beach, and Miami-Dade do in Florida. …

Strengthening the U.S. health care system

Image of globe on light, McGill University. Photo by Smallman

In our textbook, the health chapter begins by this comparison of nations: “Chile, Costa Rica, Cyprus, Guadalupe, Hong Kong, Israel, Macau, Malta, Martinique, Singapore, and the United Arab Emirates are a diverse set of nations and territories. Yet they all have one fact in common: their citizens live longer than those of the United States, as do the citizens of many developed countries (United Nations 2006). This truth is unexpected, given the wide gap between the wealth, power, and technology of these countries and that of the United States. But health inevitably becomes linked to broader issues of politics and policy.” This is certainly the case in the United States’ ability to respond to a pandemic.

What have some of the lessons of this pandemic been for the United States? Our health care system has a number of weaknesses during an epidemic:

  1. A health care system that invests heavily in technology, but less so in people, such as the public health professionals who do contact tracing.
  2. A lack of recent experience with pandemics, such as South Korea and Canada had with SARS and MERS.
  3. An inadequate stockpile of personal protective equipment. A failed effort to develop a stockpile of ventilators wasted over a decade, and left the United States undersupplied.
  4. A popular belief that epidemics are something that happens elsewhere, so that the first and best response is only to put in place border restrictions.
  5. A sense of hubris, so that outbreaks in China or South Korea are assumed to be something that could not happen here, because our hospitals -with their advanced technologies- would be able to manage the situation.
  6. A health care system in which peoples’ insurance is tied to their employment. This has meant that when people lose their employment during a pandemic, they also lose health care.
  7. Deep health inequalities, which mean that case fatality rates may vary widely depending upon class and geography.
  8. A lack of sick leave for U.S. workers, so that people feel compelled to come to work when they are sick, or to face an immediate financial crisis if they are forced to stay at home.
  9. A sense of hubris regarding the U.S. medical system, which led U.S. health authorities to reject a German developed test for COVID-19 that the World Health Organization (WHO) endorsed. Instead, the U.S. frittered away precious time developing its own test. When that did not work, the CDC and FDA wasted even more time resolving the situation.
  10. A CDC and FDA that had become too swamped by bureaucracy and hence struggled to adapt, despite having outstanding and dedicated people. The system’s senior leadership has ossified.
  11. A U.S. health care system that is too decentralized to respond to a national level emergency, although this decentralization also has some benefits when there are failures at the top.
  12. An over-reliance on overseas manufacturing for key health goods, for everything from masks to medications.
  13. A society that undervalues the very people who turn out to be particularly critical during a pandemic:  janitors, grocery store clerks, truck drivers, nurses, farmers, and others. As many people have said, it is only during a pandemic you learn whose job really counts. And there is not a good correlation between peoples’ pay and how important their job truly is. The same holds true for respect.
  14. A high rate of chronic diseases that leave people vulnerable to a disease such as COVID-19. The “diseases of development” such as diabetes, sleep apnea, high blood pressure and morbid obesity have led to higher case fatality rates. Most of these issues connect to the Standard American Diet (SAD) and the U.S. food system. No technology can replace a good diet.
  15. A chronic underfunding of public health. A good public health system is like a seat belt. You forget that it should be there until you really need it. And it seems kind of basic, but when the moment comes, there is nothing else that can replace it.
  16. Basic public health relies on people, and salaries are expensive. But not having an adequately funded public health system is what is truly expensive. Contact tracing, outreach, education, follow-up, monitoring, epidemiology, and health communication take time and people. Perhaps because they do not rely as much on technology they are also undervalued in the United States, which always likes to use technology to solve all problems. But there is no substitute for public health professionals.
  17. The basic systems that are always there in public health -nurses in schools, communication campaigns, testing systems, contract tracing- are the same systems that are needed in a pandemic. So having good public health in ordinary times gives you the tools and the people that are needed during extraordinary times.

Maps, Charts and data for COVID-19

Local market sign in Cambridge, Massachusetts, March 17, 2020

The COVID19 pandemic is now moving quickly. While northern Italy has been overwhelmed by infections, Spain and Iran are also now experiencing a disaster. Here in the United States, there are serious outbreaks in Seattle and New York. So what are the best maps and other data visualizations to keep track of what is happening? Here are my top recommendations:

Global Level Data- 冠状病毒数据

This John Hopkins map provides a global look at COVID19’s spread, combined with charts of country cases, as well as the number of dead and recovered. I would guess that this is one of the three most popular maps for tracking the pandemic.

Outbreakinfo is an outstanding dashboard, which provides a vast amount of information in a limited space. This is one of the top three sources for tracking the pandemic.

The Worldometer Coronavirus webpage has a plethora of charts with data on the outbreak, in particular country by country data on infections, new infections, deaths and recoveries.

Health map provides another global map of the outbreak, although it is not accompanied by the data in charts that accompanies the John Hopkins’ map above. It does have, however, an “animate spread” feature that shows a visual history of the virus’s spread, which is hypnotic.

The University of Washington novel Coronavirus map is similar to the John Hopkins map, but has a less cluttered (and less detailed) collection of data in charts.

A US high school student created this useful website with COVID19 data both globally and in the United States.

One Expat’s Life In China In The Time Of Corona Virus

University of Hong Kong sign

I am very grateful to Jim P. for this guest blog post.

One Expat’s Life In China In The Time Of Corona Virus
A PSU Alum’s observations

A few things to get out of the way up front. I moved to China after graduating from PSU in the summer of 2015, and getting my Type Z (Foreign Expert) visa which took a few months. I finally arrived here in late December of 2015. I live and work in the city of Yantai, on the northeast coast of the peninsula portion of Shandong Province. The city has a population of ~7 million, though it feels much smaller than Portland because it is spread out over a much larger area, and there are large swaths of agriculture (namely corn) between different areas of the city.

When the Corona virus was first announced, I was getting off work before the beginning of the two week long Spring Festival holiday (which is what most English people think of as “Chinese New Year”). The next day, I came down with a cold. Nothing like having a nasty cough when everyone is freaked out by a disease that’s major symptom is a cough (I didn’t have a fever, or flu-like symptoms). At first it seemed like most things were still open, and much like life as usual for the beginning of the holiday (except everyone had masks on). However, as soon as the fireworks were over, everybody went back inside, and ventured out rarely (mostly to take out trash). …

COVID-19 and denial

Fighting SARS Memorial, Hong Kong

Today seems to be the day in which the words and numbers that international organizations and national governments used to describe the COVID-19 pandemic increasingly diverged from facts. To begin there was an overall context in which the virus rapidly spread in the Middle East, while cases dramatically climbed in Korea (833). In the Middle East, there were new cases in Afghanistan, Bahrain, Egypt, Iraq, Israel, Lebanon, and the United Arab Emirates. Most of these cases were tied to Iranian travelers.  In Italy the number of cases rose sharply. Venice ended the remaining days of Carnival. Italians in northern Italy rushed to stores, some of which were cleaned out and left with empty shelves. In the United States, ongoing problems with testing for SARs-CoV-2 has meant that health authorities have been unable to test at scale, as in Korea, Singapore and Canada. Finally, in China the rate of increase has slowed, but the nation still has over 77,000 cases. But neither the rising number of cases nor other problems caused corresponding expressions of concern by WHO or the Iranian government.

First, Dr. Tedros at the World Health Organization (WHO) said at a press conference that the WHO would not call COVID-19 a pandemic. Indeed, the WHO has stated that it no longer uses “pandemic” as a category. At the current time, there is ongoing transmission of a novel virus in multiple world regions, with a case fatality rate of perhaps two percent. If this is not a pandemic, what would be? The goal of deleting the term pandemic seemed to be more to avoid causing fear than to accurately describe reality. If the WHO does not play the role of declaring a pandemic, then who does? The risk of this is that the public in different nations may begin to lose confidence in the WHO. The pandemic exists even if the category does not.  …

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