Hello from Nairobi.

This week’s newsletter is heavy on the ongoing hantavirus outbreak. I’m fascinated by this story. Not because the virus itself looks like it will become a global emergency (I strongly believe it won't), but because the story around it has taken on a force of its own.

We’ll also cover Indonesia's push to eliminate a type of cancer, fake rumors of shrinking genitals in central Africa, and the spiraling health crisis in Cuba.

My name is William Herkewitz, and I’m a journalist based in Nairobi, Kenya. This is the Global Health Checkup, where I highlight five of the week’s most important stories on outbreaks, medicine, science, and survival from around the world.

With that, as we say in Swahili: karibu katika habari — welcome to the news.

The hantavirus outbreak … breaks out of health news

Last week, I wrote about the hantavirus outbreak as a marginal item. An interesting story, but not quite a major event.

Since then, I’ve been gobsmacked by how far this story has traveled. Not only are most major media outlets covering the outbreak from dozens of angles and follow-ups, but it's moved well beyond the usual lane of global health stories into full zeitgeist-meme territory. 

The outbreak is clearly catching the broader public’s attention, eliciting no small amount of fear and anxiety … so what gives? Was I wrong to dismiss it?

• Disease breakdown: Hantavirus is a family of rare viruses usually carried by rodents. People typically get infected by breathing in particles from infected rodent urine, droppings, or saliva. The strain at play here is Andes virus, one of the few hantaviruses known to spread from person to person, as seen in South American outbreaks going back decades. It can cause severe respiratory illness, with symptoms appearing up to 42 days after exposure. There is no specific treatment or vaccine, so care is mostly supportive. 

First off, I won’t argue that the story isn’t captivating. It has all the ingredients of a thriller movie: a rare and deadly disease. A cruise ship unable to reach port. Wealthy, international passengers who had already disembarked and scattered across the globe. The ongoing scramble to contain and quarantine.

And yet, even with all of this, the World Health Organization and national public health agencies globally have been in full-on reassurance mode. 

Despite the attention, you can’t find serious global health professionals in panic over this outbreak. Not only has the WHO said that it “assesses the risk to the global population posed by this event as low,” but even for the people stuck on the actual cruise(!), “the risk for passengers and crew on the ship is considered moderate.”

It’s worth taking a big step back here, to break down what actually makes an infectious disease objectively frightening in an outbreak. And why this ain’t it. 

(Fair warning: What follows is my own aggressive oversimplification, but a sound and useful one.)

Let’s imagine a mad scientist had created a disease-making box with four dials that control how “scary” an outbreak gets. And the way you tweak those settings will determine whether your virus, bacteria, or parasite is a local headache or a global nightmare. Those dials are:

1. Deadliness: What are the straight odds this disease kills you? 

2. Existing medical defenses: Do we already have vaccines, treatments, or diagnostics that can fight the illness, or blunt the damage?

3. Infection window: When and how long will someone spread this disease? Are apparently healthy people passing it around for days, is it just a brief affair that requires someone to be visibly ill?

4. Finally, contagiousness: How easily does the infection spread? Are we looking at something that hangs in the air for hours like measles, or does it require close contact with infected fluids or tissues, like Ebola?

Now, if the Andes virus came out of our imaginary disease-making box, here’s where our objective fear dials would be set.

On deadliness, the dial is set to… “nightmare”! We’re looking at a fatality rate around 40%. No, not the deadliest disease we know of, but let’s not split hairs. Nobody sane would ever willingly risk those odds.

On medical defenses, the dial is also set to “maximum fear.” There is no specific treatment and no vaccine currently available for this virus, so care is mainly supportive. 

Ok, so we’re off to a terrible start.

But the infection window setting is mixed. The bad news is that symptoms can appear as late as 42 days after exposure. That long incubation period means infected people can travel far before anyone knows they are infected, potentially seeding new clusters.

But (!) there’s a crucial caveat: People are not contagious that whole time. In fact, the evidence we have suggests that people with the Andes virus are infectious only once they are visibly sick. So we’re setting this dial down to “mild alarm.”

This all brings us to the most important dial: contagiousness. And this one is set way down to “low-grade unease.” Ultimately, this is the big reason health officials are cautious, but not sounding alarms. Yes, the Andes virus is unusual among hantaviruses because it can spread from person-to-person. But the word “can” is doing a lot of work. 

As Ion Genomics has reported, the virus does not appear to be some strange new mutant. So, as in older outbreaks, person-to-person spread is largely limited to close contact with a sick person, including direct physical contact, for prolonged periods of time in an enclosed space, or exposure to body fluids. (You can see why a cruise ship is the perfect incubator.) Simply put, it just does not appear to move easily through casual contact.

That’s reassuring, because this type of spread is laggardly enough that competent public health responses can typically move faster than the virus. If officials can identify contacts, monitor them, isolate anyone who gets sick and quarantine people at highest risk, there is a very high likelihood of containing this outbreak.

Yes, that containment still requires vigilance, real work, and potentially more deaths. After all, this virus spreads and creeps in ways that do not quash instantly. But “quashing” is nevertheless where we’re headed.

Admittedly, Andes virus sounds terrifying. And for the unlucky people who get sick, it absolutely is. But scary as a disease is not the same thing as scary as an outbreak. 

And so, my big takeaway here: The objective risk and threat of this outbreak is incommensurate with the news coverage it has received.

Now, I’m not wagging my finger at the coverage. People are interested, and I get why. But don’t mistake the amount of coverage, or the, uh, “cinematic focus” of it, for a measure of how concerned you should be. 

As a threat, this hantavirus is not obviously more alarming than, say, Nipah virus: a comparably deadly infection with similar dynamics, which causes recurring outbreaks every few years in South Asia … all without a fraction of the spotlight.

What the hantavirus panic gets right

To gut-check that read, I reached out to Dr. Ronald Nahass, a clinical professor of medicine and president of the Infectious Diseases Society of America. 

He agreed with the assessment that the epidemiology here does not justify outsized worry, but argued the outbreak still revealed something real. “A public health fire drill,” as he put it, and one that showed how important clear communication still is.

First off, we spoke about why this, of all outbreaks, has captured so much attention given the reality of the disease dynamics. My imperfect theory has been that the outbreak mirrors a lot of the media dynamics of a celebrity death. 

Deaths of course happen every day, but certain deaths break through because the person or circumstances make them feel unusually vivid and close. And this story has vividness in spades. After all, “cruise from hell” is narratively almost too good. 

Also, at a certain point, public interest starts feeding on itself. The more coverage a story gets, the more it signals that this is something worth paying attention to, and so the more people want to hear about it.

Nahass broadly agreed that the narrative setting was doing a lot of work (granted, neither of us are media theorists) but he added another factor I had underweighted: the memory of Covid.

Nahass likened the event to a kind of public “PTSD” from the early days of the last pandemic. With a ship at sea, passengers trapped in uncertainty, people dying from a transmissible disease, “that is extraordinarily similar to some of the stories we heard during the Covid outbreak, and so obviously that brings back those images,” he said. “And so we all feel that.” 

Still, his greater point was this: Put aside the science for a moment, public health is about people, and the public’s reaction and interest should matter as much as the underlying epidemiology. If people are worried this could be Covid 2.0, meet them where they are.

Sure, he said, “the biology doesn’t necessarily rise to the level of a SARS virus or a novel influenza virus.” But the anxiety is real, and that “emotional toll, or anxiety toll,” he said, and the practical questions people have about what this means for them, well, that’s more than enough to make the focus worthwhile. 

And there’s a clear upside. This response is an opportunity for public health organizations to build trust, he said, and to show what a competent outbreak response actually looks like before the next real crisis arrives.

Now … as for how this moment has initially been met, Nahass was blunt enough to assign grades. He gave the WHO decent marks, especially given that no single country, and not even the WHO, had clear authority over a ship at sea. “I’d give them a B, or maybe a B-minus,” he said.

His assessment of the U.S. Centers for Disease Control and Prevention was harsher: “The CDC certainly gets a failing grade. They were absent,” he said, noting that it took the organization almost a week to put out a public response, and to Nahass, that silence fit a larger problem. Behind the scenes, the United States was missing from the kind of global outbreak response it once helped lead.

In the end, Nahass framed the ongoing hantavirus outbreak as “a public health fire drill,” one that showed how much that we still have not learned from the last pandemic. “God forbid this had been something more transmissible,” he said, noting that “we had potential vectors across the United States before we knew what it was.”

Nahass thinks the United States’ takeaway should be a wake-up call about the cost of pulling back from global health, such as departing the WHO. “We’re all interconnected,” he said, “we have to be able to respond to these kinds of events globally.” 

As for the rest of the world, I think this “fire drill” is also a useful warning at a moment when the WHO’s global pandemic treaty is still sitting unfinished, as we’ve covered extensively. 

Because next time might not be another drill.

Fake rumors of shrinking genitals … no laughing matter!

We’ve gone long on hantavirus coverage, so I’ll be brief with the other stories of the week.

Reuters covered a story about a fake disease conspiracy theory in the Democratic Republic of Congo that has become a real public health crisis. 

Last year, rumors of a mysterious illness causing men’s genitals to shrink spread through social media, local outlets, and churches in a province in the center of the country.

The rumors elicited “angry mobs [which] attacked and killed four health workers conducting vaccination research,” among other damage and deaths. “In all, at least 17 killings related to the atrophy rumor have been reported,” although Reuters could not independently verify all of them.

The story is grotesque (enough so that I’m not even attempting the obvious jokes), with a broader, painfully familiar warning. Misinformation is not background noise in public health. And it can create new dangers of its own, turning ignorance or confusion into fear and violence, directed at the very people trying to deliver much needed health care.

Cuba: an ‘epidemic of flies, rats, [and] waste’

The Guardian has a depressing follow-up on Cuba’s deepening health crisis, which we’ve reported on before. 

As a U.S. oil blockade chokes off fuel supplies, the capital city of Havana has been forced to cut back on trash collection, leaving waste piling up across the city and residents burning trash in the streets. One resident described it as “an epidemic of flies, rats, waste, and foul odors.” 

The piece tracks the obvious health risks of all that uncollected and burning waste: toxic smoke, vermin, flies, and gastrointestinal diseases. One Havana doctor told The Guardian, “at the hospital, we’ve seen an increase in hygiene-related illnesses and gastrointestinal issues.”

Less obvious, but just as worrying, trash heaps can collect rainwater in discarded plastic and other debris, causing fears of rising "mosquito-borne illnesses, with the Aedes aegypti [mosquito] species proliferating." That mosquito is one of the primary vectors for many infectious diseases, like dengue, Zika, chikungunya and yellow fever.

It’s a rough story, and Cuba’s crisis has many causes. But right now, the U.S. fuel blockade is plainly a driving force, enough so that two members of Congress wrote in The New York Times this week after visiting the island, calling for the blockade to end for medical and humanitarian reasons, even while acknowledging the failures of the Cuban government.

Indonesia’s shot at curing [a type of] cancer

We’ll finish today an inspiring piece in Think Global Health on Indonesia’s push to eliminate cervical cancer, a disease that still kills more than 20,000 women there each year.

This cancer is unique because it’s a form of the disease where most cases are caused directly by a virus. In this case, the human papillomavirus, or HPV. 

In countries like Indonesia, HPV is responsible for an estimated “94% of cervical cancer deaths.” So screening and vaccination efforts against this virus are dramatically effective at cutting cancer deaths.

The hard part, as always, is reaching the people you most need. Indonesia’s “285 million people are spread across 17,500 islands,” with a third of the government’s districts classified as remote. So the story here is ultimately about whether an ambitious national health program can reach people on the outskirts of the country. 

- William