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The Next Plague Is Coming. Is America Ready?

下一场瘟疫即将来临,美国准备好了吗?



At 6 o’clock in the morning, shortly after the sun spills over the horizon, the city of Kikwit doesn’t so much wake up as ignite. Loud music blares from car radios. Shops fly open along the main street. Dust-sprayed jeeps and motorcycles zoom eastward toward the town’s bustling markets or westward toward Kinshasa, the Democratic Republic of the Congo’s capital city. The air starts to heat up, its molecules vibrating with absorbed energy. So, too, the city.

早晨6点,太阳从地平线上升起不久,基奎特市并没有彻底苏醒过来。汽车收音机里大声播放着音乐。商店沿着主街开着。喷溅灰尘的吉普车和摩托车朝着东边的繁华市场驶去,或向西开往刚果民主共和国的首都金沙萨方向。空气开始变热,其中的分子随着吸收的能量而振动。这座城市也是如此。

By late morning, I am away from the bustle, on a quiet, exposed hilltop some five miles down a pothole-ridden road. As I walk, desiccated shrubs crunch underfoot and butterflies flit past. The only shade is cast by two lines of trees, which mark the edges of a site where more than 200 people are buried, their bodies piled into three mass graves, each about 15 feet wide and 70 feet long. Nearby, a large blue sign says in memory of the victims of the ebola epidemic in may 1995. The sign is partly obscured by overgrown grass, just as the memory itself has been occluded by time. The ordeal that Kikwit suffered has been crowded out by the continual eruption of deadly diseases elsewhere in the Congo, and around the globe.

到了上午晚些时候,我离开了这些喧嚣的生活场景,沿着一条大约五英里的满是坑洞的道路来到了一个安静的、毫无遮掩的山顶上。当我走过的时候,干燥的灌木在脚下嘎吱作响,蝴蝶飞掠而过。唯一的阴影是由两排树形成的,这些树的边缘是一个埋葬着200多人的地方,他们的尸体被堆在了三个集体墓穴中,每个坟墓大约有15英尺宽,70英尺长。在附近,一个蓝色的大标语写着纪念1995年5月埃博拉疫情的受害者。这一标语的一些部分已经杂草丛生,就像记忆本身被时间所遮挡一样。基奎特所遭受的苦难已经随着在刚果和世界各地持续爆发的致命疾病而被人们遗忘。

Emery Mikolo, a 55-year-old Congolese man with a wide, angular face, walks with me. Mikolo survived his own encounter with Ebola in 1995. As he looks at the resting place of those who didn’t, his solemn demeanor cracks a bit. In the Congo, when people die, their bodies are meant to be cleaned by their families. They should be dressed, caressed, kissed, and embraced. These intense rituals of love and community were corrupted by Ebola, which harnessed them to spread through entire families. Eventually, of necessity, they were eliminated entirely. Until Ebola, “no one had ever taken bodies and thrown them together like sacks of manioc,” Mikolo tells me.

埃默里·米卡洛是一个有着一张宽而瘦削的脸的55岁的刚果人,他正和我一起散步。米克罗本人在1995年感染上了埃博拉病毒,并且幸存了下来。当他看着那些没能幸存下来的人们安息的地方时,显得略微有点失态。在刚果,当人们死去时,他们的身体就会被他们的家人清洗干净。他们应该被穿好衣服、爱抚、亲吻和拥抱。这些强烈的爱和共同体的仪式被埃博拉病毒破坏了,它利用它们传播到整个家庭中。最终,在必要的情况下,他们被完全消灭了。米奥罗告诉我,在埃博拉病毒出现之前,“没有人像扔麻袋一样把尸体扔到一块”。

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Unlike airborne viruses such as influenza, Ebola spreads only through contact with infected bodily fluids. Even so, it is capable of incredible devastation, as West Africa learned in 2014, when, in the largest outbreak to date, more than 28,000 people were infected and upwards of 11,000 died. Despite the relative difficulty of transmission, Ebola still shut down health systems, crushed economies, and fomented fear. With each outbreak, it reveals the vulnerabilities in our infrastructure and our psyches that a more contagious pathogen might one day exploit.

与流感等通过空气传播的病毒不同,埃博拉病毒只通过接触受被感染的体液传播。即便如此,它还是有可能造成难以置信的破坏后果,正如西非在2014年所接受的教训那样,在迄今为止最大的一次疫情中,有超过28000人被感染,超过11000人死亡。尽管传播相对困难,但埃博拉仍然导致了卫生系统的关闭,摧毁了经济,并引发了恐惧。每一次爆发,它都揭示了我们基础设施以及我们的心理中的薄弱环节,一种更有传染性的病原体可能有一天会现身于世。

These include forgetfulness. In the 23 years since 1995, new generations who have never experienced the horrors of Ebola have been born in Kikwit. Protective equipment to shield doctors and nurses from contaminated blood has vanished, even as the virus has continued to emerge in other corners of the country. The city’s population has tripled. New neighborhoods have sprung up. In one of them, I walk through a market, gazing at delectable displays of peppers, eggplants, avocados, and goat meat. Pieces of salted fish sell for 300 Congolese francs—about the equivalent of an American quarter. Juicy white grubs go for 1,000. And the biggest delicacy of all goes for 13,000—a roasted monkey, its charred face preserved in a deathly grimace.

其中包括了健忘。自1995年以来的23年里,从未经历过埃博拉浩劫的新一代人出生在了基奎特。保护医生和护士免受污染血液的防护设备已经消失,尽管该病毒仍在该国其他地区继续出现。这个城市的人口增加了两倍。新的社区出现了。在其中的一个社区中,我穿过一个市场,凝视着美味的辣椒、茄子、鳄梨和山羊肉。咸鱼的售价为300刚果法郎——价格大约相当于美国的四分之一。多汁的白蛴螬要1000法郎。最美味的食物是13000法郎——那是一只烤猴子,它那烧焦的脸停留在了死亡的痛苦一刻。

The monkey surprises me. Mikolo is surprised to see only one. Usually, he says, these stalls are heaving with monkeys, bats, and other bushmeat, but rains the night before must have stranded any hunters in the eastern forests. As I look around the market, I picture it as an ecological magnet, drawing in all the varied animals that dwell within the forest—and all the viruses that dwell within them.

这只猴子让我感到惊讶。米卡洛则惊讶于只看到了一只。他说,通常情况下,这些摊位上挤满了猴子、蝙蝠和其他的丛林肉类,前一天晚上的大雨一定让东部森林里的猎人陷入了困境。当我环顾市场时,我把它想象成一个生态磁铁,吸引着来自森林里的各种各样的动物——以及所有居住在它们里面的病毒。

The Congo is one of the most biodiverse countries in the world. It was here that HIV bubbled into a pandemic, eventually detected half a world away, in California. It was here that monkeypox was first documented in people. The country has seen outbreaks of Marburg virus, Crimean-Congo hemorrhagic fever, chikungunya virus, yellow fever. These are all zoonotic diseases, which originate in animals and spill over into humans. Wherever people push into wildlife-rich habitats, the potential for such spillover is high. Sub-Saharan Africa’s population will more than double during the next three decades, and urban centers will extend farther into wilderness, bringing large groups of immunologically naive people into contact with the pathogens that skulk in animal reservoirs—Lassa fever from rats, monkeypox from primates and rodents, Ebola from God-knows-what in who-knows-where.

刚果是世界上生物多样性最丰富的国家之一。正是在这里,艾滋病毒得以开始大流行,最终辗转大半个地球,在加利福尼亚被发现。在这里,人们首次记录了猴痘。这个国家已经出现了马尔堡病毒、克里米亚-刚果出血热、基孔肯雅病毒、黄热病等疫情。这些都是人畜共患的疾病,它们起源于动物,然后传染到人类身上。无论人们在哪里进入野生生物丰富的栖息地,这种溢出效应的可能性都很高。撒哈拉以南非洲的人口在未来三十年将增加一倍以上,城市中心将进一步延伸到荒野,使得大量免疫系统脆弱的人接触到潜伏在动物体内的病原体——来自大鼠的拉沙热,来自灵长类和啮齿类动物的猴痘,以及只有上帝才知道来自何方的埃博拉病毒。



Survivors of the Kikwit Ebola epidemic (from left): Emilienne Luzolo, Shimene Mukungu, and Emery Mikolo in 1995. Mikolo, the first of the three to be infected, later donated his antibody-rich blood to Luzolo and Mukungu. (Emery Mikolo)

1995年基奎特埃博拉疫情的幸存者(从左至右):埃米利安·卢佐洛、什梅尼·穆昆古和埃默里·米卡洛。米卡洛是这三个人中第一个被感染的,后来他把自己抗体丰富的血液捐献给了卢佐洛和穆昆古。

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If Ebola hit Kikwit today, “it would arrive here easily,” Muyembe tells me in his office at the National Institute for Biomedical Research, in Kinshasa. “Patients will leave Kikwit to seek better treatment, and Kinshasa will be contaminated immediately. And then from here to Belgium? Or the U.S.?” He laughs, morbidly.

穆延贝在位于金沙萨的国家生物医学研究所的办公室里告诉我,如果埃博拉病毒今天袭击了基奎特,“它将会很容易到达这里。病人将离开基奎特寻求更好的治疗,金沙萨将立即受到感染。然后从这里到比利时?还是美国?”他笑着说道。

“What can you do to stop that?,” I ask.
“Nothing.”

“你能做些什么来阻止它?”我问道。
“什么也做不了。”

One hundred years ago, in 1918, a strain of H1N1 flu swept the world. It might have originated in Haskell County, Kansas, or in France or China—but soon it was everywhere. In two years, it killed as many as 100 million people—5 percent of the world’s population, and far more than the number who died in World War I. It killed not just the very young, old, and sick, but also the strong and fit, bringing them down through their own violent immune responses. It killed so quickly that hospitals ran out of beds, cities ran out of coffins, and coroners could not meet the demand for death certificates. It lowered Americans’ life expectancy by more than a decade. “The flu resculpted human populations more radically than anything since the Black Death,” Laura Spinney wrote in Pale Rider, her 2017 book about the pandemic. It was one of the deadliest natural disasters in history—a potent reminder of the threat posed by disease.

一百年前的1918年,一种H1N1流感病毒席卷了全世界。它可能起源于堪萨斯州的哈斯卡尔县、法国或中国,但很快就到处都是它的身影了。在两年时间里,多达1亿人丧生,占当时全球人口的5%,远远超过第一次世界大战的死亡人数。它不仅杀死了幼童、老人和病人,甚至连身体强壮和健康的人也难以幸免于难,他们被自己强烈的免疫反应搞垮了。它导致的死亡速度如此之快,以至于医院的床位被用光了,城市里的棺材也都被用光了,验尸官也无法满足开具死亡证明的要求。它将美国人的预期寿命降低了十多年。劳拉·斯宾尼在她2017年出版的关于大流行的书《苍白骑士》中写道:“自从黑死病以来,流感对人类的影响比任何事件都要大得多。”这是历史上最致命的自然灾害之一,它有力地提醒人们疾病带来的威胁。

Humanity seems to need such reminders often. In 1948, shortly after the first flu vaccine was created and penicillin became the first mass-produced antibiotic, U.S. Secretary of State George Marshall reportedly claimed that the conquest of infectious disease was imminent. In 1962, after the second polio vaccine was formulated, the Nobel Prize–winning virologist Sir Frank Macfarlane Burnet asserted, “To write about infectious diseases is almost to write of something that has passed into history.”

人类似乎经常需要这样的提醒。1948年,在第一次流感疫苗问世后不久,青霉素成为第一批大规模生产的抗生素,据报道,美国国务卿乔治·马歇尔声称,征服传染病的行动迫在眉睫。1962年,在第二种脊髓灰质炎疫苗被研制出来后,诺贝尔奖得主、病毒学家弗兰克·麦克法莱恩·伯内特爵士断言:“关于传染性疾病的文章几乎就是在撰写一些已经成为历史的东西。”

Hindsight has not been kind to these proclamations. Despite advances in antibiotics and vaccines, and the successful eradication of smallpox, Homo sapiens is still locked in the same epic battle with viruses and other pathogens that we’ve been fighting since the beginning of our history. When cities first arose, diseases laid them low, a process repeated over and over for millennia. When Europeans colonized the Americas, smallpox followed. When soldiers fought in the first global war, influenza hitched a ride, and found new opportunities in the unprecedented scale of the conflict. Down through the centuries, diseases have always excelled at exploiting flux.

事后看来,这些断言并不是很好。尽管人类在抗生素和疫苗研制方面取得了进展,并且成功地根除了天花,但人类仍然与我们从历史开始时就一直在与之抗争的病毒和其他病原体进行着同样的史诗般的战斗。当城市第一次出现时,疾病便让它们陷入了低潮,这一过程持续了数千年之久。当欧洲人殖民美洲时,天花也随之而来。当士兵们在第一次在全球性战争中作战时,流感就搭上了顺风车,并在这场前所未有的冲突中找到了新的机会。在过去的几个世纪里,疾病总是擅长利用人流量。

The White House is now home to an inattentive, conspiracy-minded president. We should not underestimate what that could mean.

白宫现在是一个注意力不集中、满脑子阴谋论的总统的家。我们不应低估这可能意味着什么。

Humanity is now in the midst of its fastest-ever period of change. There were almost 2 billion people alive in 1918; there are now 7.6 billion, and they have migrated rapidly into cities, which since 2008 have been home to more than half of all human beings. In these dense throngs, pathogens can more easily spread and more quickly evolve resistance to drugs. Not coincidentally, the total number of outbreaks per decade has more than tripled since the 1980s.

人类现在正处于其有史以来最快的变革时期。1918年全球人口近20亿;现在则有76亿人,他们已经迅速地迁移到城市中,自2008年以来,已经有超过一半的人口居住在城市里。在这些密集的人群中,病原体更容易传播,并且更迅速地进化出对药物的耐药性。无独有偶,自上世纪80年代以来,每十年爆发的疫情总数就会增加两倍多。

Globalization compounds the risk: Airplanes now carry almost 10 times as many passengers around the world as they did four decades ago. In the ’80s, HIV showed how potent new diseases can be, by launching a slow-moving pandemic that has since claimed about 35 million lives. In 2003, another newly discovered virus, sars, spread decidedly more quickly. A Chinese seafood seller hospitalized in Guangzhou passed it to dozens of doctors and nurses, one of whom traveled to Hong Kong for a wedding. In a single night, he infected at least 16 others, who then carried the virus to Canada, Singapore, and Vietnam. Within six months, sars had reached 29 countries and infected more than 8,000 people. This is a new epoch of disease, when geographic barriers disappear and threats that once would have been local go global.

全球化加剧了这种风险:如今,飞机在世界各地搭载的乘客数量几乎是40年前的10倍。在80年代,艾滋病毒显示出新的疾病有多么强大,它发起了一场缓慢移动的大流行运动,自那以来已经夺去了3500万人的生命。2003年,另一种新发现的病毒——非典病毒,明显传播得更快。一名在广州住院的中国海产品销售商将它传染给了数十名医生和护士,其中一人前往香港参加婚礼。在一个晚上,他至少感染给了另外16人,然后把病毒带到了加拿大、新加坡和越南。不到6个月,非典已经蔓延到29个国家,感染了8000多人。这是一个新的疾病时代,当地理屏障消失时,曾经是局部的威胁变成了全球性的。

Last year, with the centennial of the 1918 flu looming, I started looking into whether America is prepared for the next pandemic. I fully expected that the answer would be no. What I found, after talking with dozens of experts, was more complicated—reassuring in some ways, but even more worrying than I’d imagined in others. Certainly, medicine has advanced considerably during the past century. The United States has nationwide vaccination programs, advanced hospitals, the latest diagnostic tests. In the National Institutes of Health, it has the world’s largest biomedical research establishment, and in the CDC, arguably the world’s strongest public-health agency. America is as ready to face down new diseases as any country in the world.

去年,时值1918年流感百周年纪念,我开始研究美国是否为下一次大流行做好了准备。我完全预料到答案是否定的。在与数十位专家交谈之后,我所发现的情况更加复杂——在某些方面让人安心,但在其他方面比我想象的还要令人担忧。当然,在过去的一个世纪里,医学已经取得了很大的发展。美国有全国性的疫苗接种计划、先进的医院、最新的诊断测试。在美国国立卫生研究院,它拥有世界上最大的生物医学研究机构,而疾病防控中心可以说是世界上最强大的公共卫生机构。美国已经准备好面对世界上任何一个国家出现的新疾病。

Yet even the U.S. is disturbingly vulnerable—and in some respects is becoming quickly more so. It depends on a just-in-time medical economy, in which stockpiles are limited and even key items are made to order. Most of the intravenous bags used in the country are manufactured in Puerto Rico, so when Hurricane Maria devastated the island last September, the bags fell in short supply. Some hospitals were forced to inject saline with syringes—and so syringe supplies started running low too. The most common lifesaving drugs all depend on long supply chains that include India and China—chains that would likely break in a severe pandemic. “Each year, the system gets leaner and leaner,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It doesn’t take much of a hiccup anymore to challenge it.”

然而,就连美国也显露出了令人不安地脆弱——而且这一点在某些方面正变得越来越快。这取决于一个恰好够用的医疗经济,在这个经济中,库存是有限的,甚至是关键的物品都是按顺序排列的。这个国家使用的大部分静脉注射袋都是在波多黎各生产的,所以当去年9月 “玛利亚”飓风摧毁了这个岛屿时,这些注射袋的供应便出现了不足。一些医院被迫用注射器注射盐水,因此注射器的供应也开始减少。最常见的救命药物都依赖于包括印度和中国在内的长期供应链,这些链条很可能会在严重的疾病大流行中破裂。明尼苏达大学传染病研究和政策中心主任迈克尔·奥斯特霍尔姆说:“每年,这个系统都会变得越来越精简。挑战它并不需要太多的小麻烦。”

Perhaps most important, the U.S. is prone to the same forgetfulness and shortsightedness that befall all nations, rich and poor—and the myopia has worsened considerably in recent years. Public-health programs are low on money; hospitals are stretched perilously thin; crucial funding is being slashed. And while we tend to think of science when we think of pandemic response, the worse the situation, the more the defense depends on political leadership.

也许最重要的是,美国很容易出现同样发生在所有国家——无论贫富——的健忘和短视,而近几年来,这种短视已经变得更加严重。公共卫生项目资金不足;医院的规模非常小;关键性的资金正在被削减。当我们想到科学的时候,当我们想到疾病大流行的反应时,当情况越糟糕的时候,这股防御力量就越依赖于政治领导。

When Ebola flared in 2014, the science-minded President Barack Obama calmly and quickly took the reins. The White House is now home to a president who is neither calm nor science-minded. We should not underestimate what that may mean if risk becomes reality.

2014年埃博拉疫情爆发时,具有科学头脑的美国总统巴拉克?奥巴马冷静而迅速地执掌了大权。白宫现在则是一位既不冷静也不具有科学头脑的总统的家。如果风险成为现实,我们不应低估它可能意味着什么。



A containment vessel for infected patients (Jonno Rattman)

为受感染的病人提供的围阻舱

Bill Gates, whose foundation has studied pandemic risks closely, is not a man given to alarmism. But when I spoke with him upon my return from Kikwit, he described simulations showing that a severe flu pandemic, for instance, could kill more than 33 million people worldwide in just 250 days. That possibility, and the world’s continued inability to adequately prepare for it, is one of the few things that shake Gates’s trademark optimism and challenge his narrative of global progress. “This is a rare case of me being the bearer of bad news,” he told me. “Boy, do we not have our act together.”

比尔·盖茨——他的基金会对疾病大流行的风险进行了深入的研究——并不是一个被危言耸听所影响的人。但当我从基奎特回来与他交谈时,他描述了一个模拟场景,它显示了一场严重的流感大流行将在短短250天内导致全世界3300多万人死亡。这种可能性,以及世界仍无法为之做好充分准备的可能性,是动摇盖茨标志性的乐观主义的为数不多的因素之一,并挑战了他对全球发展的论述。他告诉我:“这是一个罕见的例子,我是一个坏消息的信使。孩子,我们没有团结一致吗?”

Preparing for a pandemic ultimately boils down to real people and tangible things: A busy doctor who raises an eyebrow when a patient presents with an unfamiliar fever. A nurse who takes a travel history. A hospital wing in which patients can be isolated. A warehouse where protective masks are stockpiled. A factory that churns out vaccines. A line on a budget. A vote in Congress. “It’s like a chain—one weak link and the whole thing falls apart,” says Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases. “You need no weak links.”

为大流行做准备最终可以归结为真实的人和有形的东西:一个忙碌的医生——当病人出现不熟悉的发烧时,他会扬起眉毛。一名从事研究旅行史的护士。病人可以被隔离起来的医院病房。一个存放着防护面具的仓库。一个生产疫苗的工厂。预算上的一行字。国会的投票。美国国家过敏和传染病研究所所长安东尼·福奇说:“这就像一个链条——一旦出现一个薄弱环节,整个链条都将崩溃。你得保证没有薄弱环节。”

Among all known pandemic threats, influenza is widely regarded as the most dangerous. Its various strains are constantly changing, sometimes through subtle mutations in their genes, and sometimes through dramatic reshuffles. Even in nonpandemic years, when new viruses aren’t sweeping the world, the more familiar strains kill up to 500,000 people around the globe. Their ever-changing nature explains why the flu vaccine needs to be updated annually. It’s why a disease that is sometimes little worse than a bad cold can transform into a mass-murdering monster. And it’s why flu is the disease the U.S. has invested the most in tracking. An expansive surveillance network constantly scans for new flu viruses, collating alerts raised by doctors and results from lab tests, and channeling it all to the CDC, the spider at the center of a thrumming worldwide web.

在所有已知的疾病大流行威胁中,流感被广泛认为是最危险的。它的各种菌株在不断变化,有时是通过它们基因的微妙突变,有时是通过戏剧性的重组。即使在非大流行的年份,当新的病毒没有席卷全球时,更熟悉的病毒株也能在全球范围内杀死50万人。它们不断变化的特性解释了为什么流感疫苗需要每年更新一次。这就是为什么一种有时比重感冒更糟糕的疾病会转变成一个大规模谋杀的怪物。这就是为什么流感是美国在追踪方面投入最多的疾病的原因。一个庞大的监控网络不断地扫描新的流感病毒,收集医生提出的警报和实验室测试的结果,并将其全部传递给疾病控制中心——它是一只位于世界范围内的网络中心的蜘蛛。

Yet just 10 years ago, the virus that the world is most prepared for caught almost everyone off guard. In the early 2000s, the CDC was focused mostly on Asia, where H5N1—the type of flu deemed most likely to cause the next pandemic—was running wild among poultry and waterfowl. But while experts fretted about H5N1 in birds in the East, new strains of H1N1 were evolving within pigs in the West. One of those swine strains jumped into humans in Mexico, launching outbreaks there and in the U.S. in early 2009. The surveillance web picked it up only in mid-April of that year, when the CDC tested samples from two California children who had recently fallen ill.

然而就在10年前,世界上人们对之准备最充分的病毒几乎让所有人都措手不及。在21世纪初,美国疾病控制中心的主要关注重点是亚洲,在那里,H5N1——被认为最有可能引发下一次大流行的流感病毒——在家禽和水禽中肆虐。但是,尽管专家们对东方鸟类的H5N1病毒感到担忧,但在西方的猪体内,新的H1N1病毒株也正在进化。其中一种猪流感病毒在墨西哥进入了人体中,并在2009年初于墨西哥和美国爆发了疫情。监控网络在当年4月中旬才开始检测,当时美国疾病控制中心对两名最近患病的加州儿童进行了检测。

One of the most sophisticated disease-detecting networks in the world had been blindsided by a virus that had sprung up in its backyard, circulated for months, and snuck into the country unnoticed. “We joked that the influenza virus is listening in on our conference calls,” says Daniel Jernigan, who directs the CDC’s Influenza Division. “It tends to do whatever we’re least expecting.”
Video: Is Trump Ready for a Global Outbreak?

世界上最先进的疾病检测网络之一在一种已经在它的后院里迅速蔓延开来,并在几个月的时间里流传开来,偷偷溜进了这个国家的病毒面前傻了眼。美国疾病控制中心流感部门的负责人丹尼尔·杰尼根说:“我们开玩笑说,流感病毒正在监听我们的电话会议。它倾向于做出我们最不期待的事情。”

The pandemic caused problems for vaccine manufacturers, too. Most flu vaccines are made by growing viruses in chicken eggs—the same archaic method that’s been used for 70 years. Every strain grows differently, so manufacturers must constantly adjust to each new peculiarity. Creating flu vaccines is an artisanal affair, more like cultivating a crop than making a pharmaceutical. The process works reasonably well for seasonal flu, which arrives on a predictable schedule. It fails miserably for pandemic strains, which do not.

流感大流行也给疫苗生产商带来了问题。大多数流感疫苗都是通过在鸡蛋中培养病毒来制造的——这种古老的方法已经被使用了70年。每一种菌株都有不同的生长状况,所以制造商必须不断地适应每一种菌株的新的特性。制造流感疫苗是一种手工活,它更像是种植作物而不是制造药物。对于季节性流感来说,这个过程是相当有效的,它的时间表是可预测的。但它在大流行菌株面前却失败了,因为后者不可预测。

In 2009, the vaccine for the new pandemic strain of H1N1 flu arrived slowly. (Then–CDC Director Tom Frieden told the press, “Even if you yell at the eggs, it won’t grow any faster.”) Once the pandemic was officially declared, it took four months before the doses even began to roll out in earnest. By then the disaster was already near its peak. Those doses prevented no more than 500 deaths—the fewest of any flu season in the surrounding 10-year period. Some 12,500 Americans died.

2009年,新型的H1N1流感病毒的疫苗姗姗来迟了。(然后,疾控中心主任汤姆·弗里登告诉媒体,“即使你对鸡蛋大喊大叫,它也不会生长得更快。”)一旦大流行正式被宣告,疫苗最快也需要四个月的时间才能铺开供货。到那时,灾难已经接近顶峰了。这些疫苗只能阻止500人的死亡——这是近10年来流感季节中最少的。大约12500美国人死于这次流感。

The egg-based system depends on chickens, which are themselves vulnerable to flu. And since viruses can mutate within the eggs, the resulting vaccines don’t always match the strains that are circulating. But vaccine makers have few incentives to use anything else. Switching to a different process would cost billions, and why bother? Flu vaccines are low-margin products, which only about 45 percent of Americans get in a normal year. So when demand soars during a pandemic, the supply is not set to cope.

这种以鸡蛋为基础的系统依赖于鸡,而它们自身也容易感染流感。由于病毒可以在卵内发生变异,因此产生的疫苗并不总是与正在传播的病毒菌株相匹配。但是疫苗生产商几乎没有什么动力去使用其他的东西。切换到一个不同的流程将花费数十亿美元,为什么还要自找麻烦呢?流感疫苗是一种低利润的产品,只有大约45%的美国人会在正常年份使用它。因此,当大流行期间需求飙升时,供应也就无法应对了。

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As I walk down a seventh-floor hallway of the University of Nebraska Medical Center, Kate Boulter, a nurse manager, points out that the carpet beneath my feet has disappeared, exposing bare floors that are more easily cleaned. In an otherwise unmarked corridor, this, she says, is the first sign that I am approaching the biocontainment unit—a special facility designed to treat the victims of bioterror attacks, or patients with a deadly infectious disease such as Ebola or sars.

当我走在内布拉斯加大学医学中心的七楼走廊上时,护士长凯特·鲍特指出我脚下的地毯已经消失了,露出了更容易清洗的裸露地板。她说,在另一个未被注意到的走廊里,这是表明我正在接近生物防护装置——一种特殊的设施,它旨在治疗生物恐怖袭击的受害者,或者是感染了埃博拉或非典等致命传染病的病人——的第一个标志。

There is nothing obviously special about the 4,100 square feet, but every detail has been carefully designed to give patients maximal access to the best care, and viruses minimal access to anything. A supply room is stocked with scrubs, underwear, and socks, so that no piece of clothing staff members wear at work will make its way home. There are two large autoclaves—pressure cookers that use steam to sterilize equipment—so that soiled linens and clothes can be immediately decontaminated. The space is under negative air pressure: When doctors enter the hallway, or any of the five patient rooms, air flows in with them, preventing viruses from drifting out. This also dries the air. Working here, I’m told, is murder on the skin.

在这个面积达4100平方英尺的地方没有什么特别的东西,但是每一个细节都经过了精心设计,使病人能够获得最大限度的最佳护理,并且最小化病毒的传播。一间供应室里堆满了磨砂、内衣和袜子,这样一来,工作人员在工作中所穿着的所有衣服都不会被带回家了。那里有两个大型的高压灭菌器——用蒸汽来消毒设备的高压锅——这样,肮脏的床单和衣服就可以被立即消毒了。这个空间处于负气压下:当医生进入走廊,或五间病房中的任何一个时,空气就会流入,以防止病毒飘出。这也会使空气变得干燥。我被告知,在这里工作会对皮肤造成损害。



Mother and baby mannequins used for practicing treatment (Jonno Rattman)

用于治疗的母亲和婴儿人体模型

Almost everything in the unit is a barrier of some form. Floor seams are welded. Light and plumbing fixtures are sealed. The ventilation and air-conditioning systems are separate from those for the rest of the hospital, and rigorously filtered. Patients can be wheeled in on a tented gurney with built-in glove ports; it looks like a translucent caterpillar whose legs have been pushed inward. A separate storage room is stocked with full-body suits, tape for sealing the edges of gloves, and space-suit-like hoods with their own air filter. A videoconferencing system allows team members—and family—to monitor what happens in the patient rooms without having to suit up themselves. A roll of heavy-duty metallic wrapping paper can be used to seal the body of anyone who dies.

这个部门里的几乎所有的东西都是某种形式的障碍。地板接缝被焊接起来。照明和管道设备是密封的。通风和空调系统与医院的其他部分相分离,并经过了严格过滤。病人可以被推到一个有内置手套操作端口的帐篷里;它看起来就像一只半透明的毛毛虫,只不过它的腿被推到里面去了。一个单独的储藏室里放满了全身密封套装,手套的边缘被用胶带封住了,还配备有带着自己的空气过滤器的太空服式的兜帽。视频会议系统可以让团队成员和家人监控病人房间里发生的事情,而不必身处其中。一卷重型金属包装纸可以用来封住任何死去的人的尸体。

The unit is currently empty, as it has been for most of its existence. The beds are occupied only by four hyperrealistic mannequins, upon which nurses can practice medical procedures while wearing cumbersome protective layers. “We’ve named all the mannequins,” Boulter tells me. Pointing to the largest one: “That one’s Phil, after Dr. Smith.”

这个部门目前是空置的,正如它存在的大部分时间一样。这些床位只是被四个超现实的人体模型所占据,护士们可以在穿着笨重的防护服的同时展开医疗程序。“我们给所有的人体模型都命名了,”鲍特告诉我,他指着最大的那个人体模型说道:“那个是菲尔,以史密斯博士之名命名的。”

Phil Smith began pushing the hospital to build the biocontainment unit in 2003, back when he was a professor of infectious diseases. sars had emerged from nowhere, and monkeypox had broken out in the Midwest; Smith realized the U.S. had no facilities that could handle such diseases, beyond a few high-security research labs. With support from the state health department, he opened the unit in 2005.

2003年,菲尔·史密斯开始推动医院建造生物防护装置单元,当时他还是传染病学教授。非典不知从什么地方冒了出来,美国中西部地区也突然爆发了猴痘;史密斯意识到,除了一些安全性很高的研究实验室之外,美国还没有能够处理这些疾病的设施。在国家卫生部门的支持下,他于2005年开设了这个单元。

And then, nothing happened.

然后,什么也没发生。

For nine years, the facility was dormant, acting mostly as an overflow ward. “We didn’t know if it would be needed, but we planned and prepared as if it would,” says Shelly Schwedhelm, the head of the hospital’s emergency-preparedness program, who for years kept the unit afloat on a shoestring budget. Her efforts paid off in September 2014, when the State Department called, telling Schwedhelm and her team to prepare for possible Ebola patients. Over 10 weeks, the unit’s 40 staff members took care of three infected Americans who had been evacuated from West Africa. They worked around the clock in teams of six, some staffers treating the patients directly, others helping their colleagues put on and take off their gear, and still others supervising from the nurses’ station. Two of the patients—Rick Sacra, a physician, and Ashoka Mukpo, a journalist—were cured and discharged. The third—a surgeon named Martin Salia—was already suffering from organ failure by the time he arrived, and died two days later. A green-marble plaque now hangs in the unit to honor him.

9年来,该部门一直处于闲置状态,它主要被用作备用病房。“我们不知道是否需要,但我们做了计划和准备,就像它将会发生那样”,医院应急准备项目的负责人谢莉·施韦德海姆如此说道,她多年来一直保持着这个单元的预算。她的努力在2014年9月获得了回报,当时美国国务院打电话告知施韦德海姆和她的团队为可能的埃博拉患者做准备。在过去的10周时间里,该部队的40名工作人员照顾了三名从西非撤离的受感染的美国人。他们24小时六班倒地工作,一些工作人员直接治疗病人,另一些人则帮助他们的同事穿上和脱下他们的装备,还有一些人从护士站进行监督。其中两名患者——医生瑞克·萨布拉和记者阿舒卡穆波——被治愈出院。第三名患者——一位名叫马丁·萨利亚的外科医生到达此处的时候已经遭受了器官衰竭的折磨,他在两天后就去世了。一个绿色的大理石板现在挂在这个单元里以纪念他。



A plaque memorializing Dr. Martin Salia, who died from Ebola at the University of Nebraska Medical Center in 2014 (Jonno Rattman)

2014年在内斯加州大学医学中心纪念死于埃博拉的马丁·萨利亚博士的大理石板

The University of Nebraska Medical Center is one of the best in the country at handling dangerous and unusual diseases, Ron Klain, who was in charge of the Obama administration’s Ebola response, tells me. Only the NIH and Emory University Hospital have biocontainment units of a similar standard, he says, but both are smaller. Those three hospitals were the only ones ready to take patients when Ebola struck in 2014, but within two months, Klain’s team had raised the number to 50 facilities. It was “a lot of hard work,” he says. “But ultimately, we had 144 beds.” A more contagious and widespread disease would have overwhelmed them all.

负责奥巴马政府中的埃博拉应对工作的罗恩·克兰告诉我,内斯加州大学医学中心是美国处理危险和不寻常疾病的最佳医院之一。他说,只有美国国家卫生研究院和艾莫利大学医院拥有类似标准的生物防护装置,但这两者的规模都更小。这三家医院是2014年埃博拉疫情爆发时唯一准备接收患者的医院,但在两个月内,克兰的团队已经将这一数字提高到了50家。他说,这是“一项艰巨的工作。但最终,我们拥有了144个床位。”一种更有传染性、更广泛的疾病会让他们不堪重负。

Preparing hospitals for new epidemics is challenging in the United States, Klain says, because health care is so decentralized: “You and I could decide that every hospital should have three beds capable of isolating people with a dangerous disease, and Trump could agree with us, and there’s no way of making that happen.” Hospitals are independent entities; in this fractured environment, preparedness is less the result of governmental mandate and more the product of individual will. It comes from dedicated visionaries like Smith and skilled managers like Schwedhelm, who can keep things going when there’s no immediate need.

克兰说,为新传染病准备医院的工作正在挑战着美国,因为医疗力量是非常分散的:“你和我可以决定每个医院都应该保证有三个能够隔离患有危险的疾病的病人的床位,而特朗普可能会同意我们的意见,并现在没有办法让这种情况成为现实。”医院是独立的实体;在这个支离破碎的环境中,防备与其说是政府授权的结果,不如是个人意志的产物。它来自像史密斯这样的有远见的有远见的人,以及像施韦德海姆这样的技术官僚,当他们没有迫切需要的时候,他们可以让事情保持原来的状态。

The trio of Ebola patients in 2014 produced 3,700 pounds of contaminated linens, gloves, and other waste among them, all of which demanded careful handling. Treating them cost more than $1 million. That kind of care quickly reaches its limits as an epidemic spreads. In June 2015, the Samsung Medical Center, in Seoul—one of the most advanced medical centers in the world—was forced to suspend most of its services after a single man with mers arrived in its overcrowded emergency room. American hospitals wouldn’t fare much better. But at the very least, they can plan for the worst.

2014年,这三名埃博拉患者产生了3700磅被污染的亚麻、手套和其他废弃物,所有这些都需要被小心处理。处理它们的费用超过了100万美元。随着流行病的蔓延,这种护理很快就达到了极限。2015年6月,位于首尔的三星医疗中心——世界上最先进的医疗中心之一——被迫暂停了大部分服务,原因是一名中东呼吸综合征患者抵达了人满为患的急诊室。美国医院的情况不会好上多少。但至少,他们可以做最坏的打算。

Schwedhelm, with a 100-person team, has been creating plans for how every aspect of hospital operation would need to work during a pandemic. How much should hospitals stockpile? How would they provide psychological support during a weeks-long crisis? How could they feed people working longer-than-usual shifts? When would they cancel elective surgeries? Where could they get extra disinfectant, mop heads, and other cleaning supplies?

带领一支百人团队的施韦德海姆一直在制定计划,以便让医院的各个方面在疾病大流行期间正常运转。医院应该储备多少物资?在长达数周的危机中,他们将如何提供心理支持?他们怎么才能照顾那些那些比平常轮值工作时间更长的人呢?他们什么时候才能选择性地取消手术?他们可以从哪里获得额外的消毒剂、拖把头和其他清洁用品?

At a single meeting, I hear two dozen people discuss how they would care for the 400 or so patients on the hospital’s organ-transplant list. How would they get such patients into the facility safely? At what point would it become too risky to pump them with immunosuppressants? If ICUs are full, where could they create clean spaces for post-transplant recovery? It matters that the hospital has considered these questions. It matters just as much that the people in charge have met, talked, and established a bond.

在一次会议上,我听到有24人在讨论他们将如何照顾医院器官移植名单上的400名左右的患者。他们如何让这些患者安全地进入医院?在什么情况下,给他们服用免疫抑制剂会变得过于危险?如果重症监护室人满为患,那么他们可以在哪里为移植后的恢复创造干净的空间呢?重要的是医院已经考虑到了这些问题。同样重要的是,相关负责人已经相互认识、交谈并建立了联系。

The members of the team running the biocontainment unit all work in different parts of the hospital, as pediatricians, critical-care specialists, obstetricians. But even during the unit’s long dormancy, Schwedhelm would gather them for quarterly training sessions. That’s why, when the moment came, they were ready. When they escorted the Ebola patients off their respective planes, the staff members recalled what they had learned during practice drills.

负责生物安全的团队的成员都在医院的不同部位工作,包括儿科医生、关键护理专家、产科医生。但即使是在该部门被长期闲置期间,Schwedhelm也会召集他们进行季度培训。这就是为什么当那一刻到来的时候,他们已经做好了准备。当他们护送埃博拉患者离开各自的飞机时,工作人员回忆起了他们在演习中所学到的东西。



Shelly Schwedhelm, who directs Nebraska’s emergency-preparedness program, and Phil Smith, who opened the hospital’s biocontainment unit in 2005 (Jonno Rattman)

内布拉斯加州紧急预防项目的负责人谢莉·施韦德海姆和在2005年了医院的生物防护装置的菲尔·史密斯

“We do a lot of team building,” Boulter says, showing me a photo of the group at a ropes course.
“It was the scariest thing I’ve ever done,” Schwedhelm says. They followed that up with something more sedate—a movie night in the hospital auditorium. They watched Contagion.

鲍特说:“我们做了很多团队建设,”他向我展示了一组在攀绳梯课程中的小组照片。
“这是我做过的最可怕的事情,”施韦德海姆说。他们随后又安排了一些更安静的活动——医院礼堂里的一个电影之夜。他们看着电影是《传染病》。

Kikwit General Hospital has no biocontainment unit. Instead, it has Pavilion 3.

基奎特总医院没有生物防护装置。相反,它有一顶3号病房楼。

Emery Mikolo, who works at the hospital as a nurse supervisor, takes me into the blue-walled, open-windowed building that is now the pediatrics ward. In one room, mosquito nets are suspended hammocklike over 16 closely packed beds, on which mothers care for young children and newborn babies. This is a place of new life. But in 1995, it was the infamous “death ward,” where Ebola patients were treated. Exhausted doctors struggled to control the outbreak; outside the hospital, the military established a perimeter to turn back fleeing patients. The dead were laid in a row on the pavement.

埃默里·米卡洛在医院担任护士主管,他带我进入了一幢蓝墙、开窗的建筑,这里现在被用作儿科病房。在一个房间里,蚊帐被悬挂在16张分部密集的床上,母亲们在那里照顾年幼的孩子和刚出生的婴儿。这是一个新生命之地。但在1995年,它却是臭名昭著的“死亡病房”,埃博拉患者在那里接受了治疗。精疲力竭的医生们努力控制疫情;在医院之外,军方建立了一个隔离带,以阻挡逃跑的病人。死者则被放在人行道上,排成一排。

We walk into another room, which is largely empty except for a poster of a cartoonish giraffe, a few worn mattresses, and some old bed frames. Mikolo touches one of them. It was his, he says. He looks around quietly and shakes his head. Many of the people who shared this room with him were his colleagues who had become infected while they cared for patients. Ebola’s symptoms are sometimes mythologized: Organs don’t liquefy; blood seldom pours from orifices. But the reality is no less gruesome. “It was like a horror movie,” he says. “All these people I worked with—my friends—throwing up, screaming, dying, falling out of bed.” At one point, delirious with fever, he too rolled off his mattress. “There was vomit and piss and shit on the ground, but at least it was cool.”

我们走进了另一个房间,那里除了一张长颈鹿的卡通海报,一些破旧的床垫和一些旧的床架外,空空如也。米卡洛触碰了其中的一个物件。他说,这是他用过的。他静静地环顾四周,摇了摇头。许多和他一起住在这个房间的人都是他的同事,他们在照顾病人的时候被感染了。埃博拉病毒的症状有时会被神话化:器官不会液化;血很少从孔口中涌出。但现实也同样可怕。“这就像一部恐怖电影,”他说道,“所有和我一起工作的人——我的朋友们——都在呕吐,尖叫,死亡,从床上掉下来。”有一次,他因为发烧而精神错乱,他也从床垫上滚了下来。“地上有呕吐物、小便和大便,但至少它很酷。”

Many of the people who worked at the hospital during the outbreak are still there. Jacqui, a nurse, worked in Pavilion 3 and returned there only three years ago. She was terrified at first, but she soon habituated. I ask whether she’s worried that Ebola might return. “I’m not afraid,” she says. “It’s never coming back.”

在疫情爆发期间,许多在医院工作的人仍然待在那里。雅基是一名曾在3号病房楼工作的护士,她三年前才回到那里。一开始她很害怕,但很快就习惯了。我问她是否担心埃博拉病毒会卷土重来。她说:“我不害怕,它永远都不会回来了。”

If it does, is there any protective equipment at the hospital? “No,” she tells me.

如果它卷土重来的话,医院里有防护设备吗?“没有”,她告诉我。

Mikolo laughs. “Article 15,” he says.

米卡洛笑了。他说道:“第十五条”。

Article 15 is something of a Congolese catchphrase, referring to a fictional but universally recognized 15th article of the country’s constitution, “Débrouillez-vous”—“figure it out yourself.” I hear it everywhere. It is simultaneously a testament to the Congolese love for droll humor, a weary acknowledgment of hardship, a screw-you to the establishment, and a motivational mantra. No one’s going to fix your problems. You must make do with what you’ve got.

第十五条是一句刚果语的流行语,指的是一个虚构的,但被普遍认可的国家宪法第15条——“自己去解决吧。”我在任何地方都能听到这句话。这同时也证明了刚果人对幽默的喜爱,对苦难的厌倦,对体制的蔑视,以及一种起到激励作用的咒语。没有人会解决你的问题。你必须依靠自己所拥有的东西来完成。

Though the U.S. is vastly wealthier than the Congo, the laments I heard in both countries about how things could go wrong were uncannily similar.

尽管美国比刚果富裕得多,但我在这两个国家听到的关于事情可能会如何出错的哀叹却惊人的相似。

In a nearby room, dried blood dots the floor around an old operating table, where a sick lab technician once passed Ebola to five other medical staff members, starting a chain of transmission that eventually enveloped Mikolo and many of his friends. The phlebotomist who drew the blood samples that were used to confirm Ebola also still works at the hospital. I watch as he handles a rack of samples with his bare hands. “Ask someone here, ‘Where are the kits that protect you from Ebola?,’?” Donat Kuma-Kuma Kenge, the hospital’s chief coordinator, tells me. “There aren’t any. I know exactly what I’m meant to do, but there are no materials—here, in the place where there was Ebola.

在附近的一个房间里,干掉的血点留在了一个旧手术台上的地板上,一名生病的实验室技术人员曾经把埃博拉病毒传染给其他5名医务人员,从而开始了一连串的传播,最终将米卡洛和他的许多朋友卷入其中。抽取血液样本的抽血师仍然在医院工作。他提取了用于确认埃博拉病毒的血液样本。我看着他赤手空拳处理一堆样品。“问问这里的人,那些保护你免受埃博拉病毒侵害的工具包在哪里?”这家医院的首席协调官多纳特·库玛-库玛·根盖告诉我,“一件都没有。我清楚地知道我该做什么,但这里没有任何物资——这里可是埃博拉病毒爆发的地方。”

“Débrouillez-vous,” he adds.

“自己去解决吧”他补充道。

The hospital’s challenges are considerable, but as I walk around, I realize that they are familiar. Even though the United States is 500 times as wealthy as the Congo, the laments I heard from people in both countries were uncannily similar—different in degree, but not in kind. Protective equipment is scarce in the Congo, but even America’s stockpiles would quickly be depleted in a serious epidemic. Unfamiliarity with Ebola allowed the virus to spread among the staff of Kikwit’s hospital, just as it did among nurses in Dallas, where an infected patient landed in September 2014. In Kikwit, a lack of running water makes hygiene a luxury, but even in the U.S., getting medical professionals to wash their hands or follow other best practices is surprisingly hard; every year, at least 70,000 Americans die after picking up infections in hospitals. And most of all, the people in both countries worry that brief spates of foresight and preparedness will always give way to negligence and entropy.

这家医院面临的挑战是相当大的,但当我四处走动时,我意识到这种情况很令人熟悉。尽管美国的富裕程度是刚果的500倍,但我从两国人民那里听到的哀叹却出奇地相似——在程度上不同,但都不是很好。在刚果,防护装备很匮乏,但即使是美国的库存也会在严重的流行病中迅速耗尽。不熟悉埃博拉病毒使得该病毒在基奎特医院的工作人员中传播,就像达拉斯的护士所遇到的情况一样,2014年9月,一名受感染的病人出现在了那里。在基奎特,缺乏自来水使卫生成为一种奢侈品,但即使在美国也是如此。让医疗专业人士洗手或遵循其他最佳做法是非常困难的;每年,至少有7万美国人在医院受到感染后死亡。最重要的是,这两个国家的人民都担心,一时的远见和准备总是会让位于疏忽和趋于混乱的趋势。

In the U.S., attention and money have crested and then crashed with each new crisis: anthrax in 2001, sars in 2003. Resources, hurriedly assembled, dwindle. Research into countermeasures fizzles. “We fund this thing like Minnesota snow,” Michael Osterholm says. “There’s a lot in January, but in July it’s all melted.”

在美国,关注度和金钱支持已经达到顶峰,然后它会随着每一场新的危机而崩溃:2001年的炭疽热,2003年的非典。资源被急忙组合在一起,然后减少。对策研究失败了。“我们发现它就像明尼苏达的雪一样,”迈克尔·奥斯特霍尔姆说,“1月份有很多资源,但到了7月,一切都融化了。”

Take the Hospital Preparedness Program. It’s a funding plan that was created in the wake of 9/11 to help hospitals ready themselves for disasters, run training drills, and build their surge capacity—everything that Shelly Schwedhelm’s team does so well in Nebraska. It transformed emergency planning from an after-hours avocation into an actual profession, carried out by skilled specialists. But since 2003, its $514 million budget has been halved.

就拿医院准备计划来说。这是一项在911事件后建立的资助计划,帮助医院做好准备应对灾难,进行训练演习,并构建他们的过负荷能力——谢莉·施韦德海姆的团队在内斯加州把这一切做得很好。它将应急计划从下班后的业余爱好转变为一种由熟练专家从事的实际职业。但自2003年以来,其514亿美元的预算已经减半。

Another fund—the Public Health Emergency Preparedness program—was created at the same time to help state and local health departments keep an eye on infectious diseases, improve their labs, and train epidemiologists. Its budget has been pruned to 70 percent of its $940 million peak. Small wonder, then, that in the past decade, local health departments have cut more than 55,000 jobs. That’s 55,000 people who won’t be there to answer the call when the next epidemic hits.

另一个基金——公共卫生应急计划——也在同时成立,以帮助州和地方卫生部门密切关注传染病,改善他们的实验室,并培训流行病学家。它的预算已经削减到其9.4亿美元峰值的70%。因此,在过去的十年里,当地的卫生部门已经削减了超过5.5万个工作岗位,也就不足为奇了。当下一次流行病来临的时候,有5.5万人不会再去接电话。

These sums of money are paltry compared with what another pandemic might cost the country. Diseases are exorbitantly expensive. In response to just 10 cases of Ebola in 2014, the U.S. spent $1.1 billion on domestic preparations, including $119 million on screening and quarantine. A severe 1918-style flu pandemic would drain an estimated $683 billion from American coffers, according to the nonprofit Trust for America’s Health. The World Bank estimates that global output would fall by almost 5 percent—totaling some $4 trillion.

与另一场疾病大流行可能给这个国家造成的损失相比,这些钱是微不足道的。疾病的代价过于高昂。作为对2014年仅10例埃博拉病例的回应,美国在国内准备工作上花费了11亿美元,其中包括1.19亿美元用于筛查和隔离的经费。根据美国健康信托基金会的数据,一场1918年式的严重流感将让美国国库支出683亿美元。世界银行估计,全球产出将下降近5个百分点,总计约4万亿美元。

The U.S. is not unfamiliar with the concept of preparedness. It currently spends roughly half a trillion dollars on its military—the highest defense budget in the world, equal to the combined budgets of the next seven top countries. But against viruses—more likely to kill millions than any rogue state is—such consistent investments are nowhere to be found.

美国对准备的概念并不陌生。目前,它在军事上的花费大约是5000亿美元——这是世界上最高的国防预算,相当于后面七个国家的总预算。但是,对于病毒而言——它比任何流氓国家更有可能杀死数百万人——这种持续的投资无处可寻。



A worker sealing her gloves (Jonno Rattman)

一名工作人员在密封她的手套

At a modern building in Holly Springs, on the outskirts of Raleigh, North Carolina, I walk down a wide corridor where the words it really is a matter of life and death have been stenciled on a yellow wall. The walkway leads to a refrigerator-cool warehouse, where several white containers sit on a blue pallet. The containers are full of flu vaccine, and each holds enough to immunize more than 1 million Americans. When their contents are ready to be used, they head toward a long, Rube Goldberg–esque machine that dispenses the vaccine into syringes—more than 400,000 a day.

在北卡罗来纳州罗利市郊区圣泉市的一栋现代建筑里,我走在一条宽阔的走廊上,如果可能的话,这里真的是一个生死攸关之所,死亡已经被印在了黄色的墙上。这条走道通向一个冷藏库,在那里有几个白色的容器被放在一个蓝色的托盘上。这些容器里装满了流感疫苗,每一个容器都装有足够给100万美国人注射的疫苗。当其中的疫苗准备被使用时,它们就会移往一个长长的鲁布·戈德堡式的机器,把疫苗分配到注射器里——每天多达40多万剂。

Instead of eggs, the facility grows flu viruses in lab-grown dog cells, which fill 5,000-liter steel vats one floor above. The cells are infected with flu viruses, which quickly propagate. The technique is faster than using eggs, and produces vaccines that are a closer match to circulating strains.

该设备不是通过鸡蛋,而是在实验室培育的狗细胞中培养流感病毒,这些细胞填满了地板上5000升容量的钢桶。这些细胞被感染了很快就会传播开来的流感病毒。这项技术比使用鸡蛋要快,并且能够生产出与流行毒株更接近的疫苗。

This facility is the result of a partnership between the pharmaceutical company Seqirus and a government agency called the Biomedical Advanced Research and Development Authority. Established in 2006, barda acts more or less as a venture-capital firm, funding the development of vaccines, drugs, and other epidemic countermeasures that would otherwise be unprofitable. In 2007, it entered into a $1 billion partnership to create the Holly Springs plant, which started making vaccines in 2011. “No one would have taken the risk of disposing of egg manufacturing unless they could reach the scale we have here,” says Marie Mazur, Seqirus’s vice president of pandemic response.

该设施是制药公司Seqirus与一家被称为生物医学高级研究与开发局的政府机构合作的结果。成立于2006年的生物医学高级研究与开发局多少可以算是一家风险投资公司,它为疫苗、药品和其他可能无利可图的流行病解决方案提供资金。2007年,该公司达成了一项10亿美元的合作计划,创建了圣泉市工厂,该工厂于2011年开始生产疫苗。“没有人会去冒使用鸡蛋制造疫苗的风险,除非他们能达到我们所拥有的这种规模,” Seqirus的流行病应对副总裁玛丽·马祖尔如此说道。

The facility will soon be able to make 200 million doses of vaccine within the first six months of a new pandemic—enough to immunize more than one in every three Americans. Six months is still a long time, though, and there are limits to how quick the process can be. To vaccinate people during that window, Seqirus also prepares vaccines against the flu strains that barda deems most likely to cause a pandemic. Those doses are stockpiled, and can be used to immunize health-care workers, government employees, and the military while the Holly Springs plant churns out more.

该设施很快就能在新流感大流行的头六个月内生产2亿剂疫苗——足以使每3个美国人中就有超过1人接种疫苗。然而,六个月仍然是很长的一段时间,而且这个过程的速度是有限的。为了在此期间为人们接种疫苗,Seqirus还为生物医学高级研究与开发局认为最有可能导致大流行的流感毒株准备好疫苗。这些疫苗将被储存起来,可以用来给卫生保健工作者、政府雇员和军队进行免疫接种,而圣泉市的工厂则会生产更多的疫苗。

Yet even this strategy is imperfect. When H7N9 first appeared in China, in 2013, the plant did its job, creating a vaccine that was then stockpiled. Since then, H7N9 has mutated, and the hoarded doses may be ineffective against the current strains. “We occasionally have to chase a pre-pandemic,” says Anthony Fauci, the National Institute of Allergy and Infectious Diseases (niaid) director. “We have to do it,” but the strategy remains wasteful and reactive.

然而,即使是这种策略也是不完美的。2013年,当H7N9首次出现在中国时,该工厂完成了自己的工作,制造了一种后来被储存起来的疫苗。从那以后,H7N9病毒发生了变异,而囤积的剂量可能对当前的菌株是无效的。美国国家过敏和传染病研究所的主任安东尼·福奇说:“我们往往不得不抓住一场疾病大流行前的机会。我们必须这么做”,但这种策略仍然是很浪费和被动的。

What society really needs, Fauci tells me, is a universal flu vaccine—one that protects against every variant of the virus and provides long-term protection, just as the vaccines against measles and mumps do. One vaccine to bind them all: It’s hard to overstate what a win that would be. No more worrying about strain mismatches or annual injections. “It would be the epitome of preparedness,” Fauci says, and he has committed his institute to developing one.

福奇告诉我,社会真正需要的是一种通用的流感疫苗——它可以预防各种病毒的变种,并提供长期的保护,就像预防麻疹和腮腺炎的疫苗一样。一种将他们捆绑在一起的疫苗:好不夸大地说,这将是一场胜利。人们不再担心菌株不匹配或每年都要注射疫苗。“这将是疾病预防的一个象征,”福奇说道,他已经让他的研究所致力于研发这种疫苗。



Anthony Fauci, who as head of the National Institute of Allergy and Infectious Diseases has, until now, helped every president starting with Ronald Reagan manage pandemic risk, says the responses of the presidents varied widely. He has yet to meet with Donald Trump. (Jonno Rattman)

到目前为止,国家过敏和传染病研究所的负责人安东尼·福奇已经帮助从罗纳德·里根开始的每一位总统管理疾病大流行的风险,他说每位总统的反应各不相同。他还没有与唐纳德?特朗普见过面。

Flu viruses are studded with a molecule called hemagglutinin (the H in H1N1 and other such names), which looks like a stumpy Pez dispenser. Vaccines target the head, but that’s the part that varies most among strains, and evolves most quickly. Targeting the stem, which is more uniform and stable, might yield better results. The stem, however, is usually ignored by the immune system. To draw attention to it, Fauci’s team decapitates the molecule and sticks the stem onto a nanoparticle. The result looks like a flu virus, but encourages the immune system to go after the stable stem instead of the adaptable head. In a preliminary study, his team used this approach to build a vaccine using an H1 virus, which then protected ferrets against a very different H5N1 strain.

流感病毒中有一种叫做血球凝集素的分子(也就是H1N1和其他类似的名字中的H),它看起来就像一个矮胖的糖果盒。疫苗的目标便是它的头部,但这部分在不同的菌株中变化最大,而且进化速度最快。瞄准更均匀、更稳定的干茎可能会产生更好的结果。然而,这种干茎通常被免疫系统所忽视。为了引起人们的注意,福奇的团队将这种分子剥离,并将其粘在纳米粒子上。这个结果看起来就像一种流感病毒,但它可以鼓励免疫系统去追逐稳定的干茎,而不是适应性强的头部。在一项初步研究中,他的研究小组使用这种方法,利用H1病毒制造了一种疫苗,这种病毒可以保护雪貂对抗另一种非常不同的H5N1菌株。

This type of work is promising, but flu is such an adaptive adversary that the quest for a universal vaccine might take years, even decades, to fulfill. Progress will be incremental, but each increment will have value in itself. A universal-ish vaccine that, say, protected against all H1N1 strains would have prevented the 2009 pandemic. And reducing flu’s menace, even in some of its variants, would free up resources and intellectual capacity for dealing with other deadly diseases for which no vaccines exist at all.

这种类型的工作是有希望的,但是流感是一个适应性很强的对手,寻求通用疫苗的目标可能需要数年甚至几十年才能实现。进步将是渐进的,但每一个增量本身都是有价值的。一种普世性的疫苗据说可以预防所有的H1N1病毒株,从而阻止了2009年的大流行。减少流感的威胁——即使是针对它的一些变体——也会释放出资源和人才来处理其他致命的疾病,而这些疾病根本就没有疫苗可用。

Many of those diseases strike poor countries first and are—for now—rare. Creating vaccines for them is painstaking and often unprofitable, and therefore little gets done. Last year, to help change that, the Coalition for Epidemic Preparedness Innovations was created, and now has $630 million pledged by governments and nonprofits. It will focus first on Lassa fever, Nipah, and mers, and its ambition is to yank promising vaccines out of developmental purgatory, push them through trials, and stockpile them by the hundreds of thousands. (One goal is to avoid a repeat of 2014, when Ebola ravaged West Africa while an experimental vaccine that could potentially have stopped it was languishing in a freezer, where it had been for a decade.)

许多疾病首先袭击了贫穷国家,而且它们——就现在而言——是罕见的。为它们制造疫苗是一件苦差事,而且常常是无利可图的,因此很少有人能够完成。去年,为了帮助改变这一状况,流行病防范创新联盟得以成立,政府和非营利组织承诺向它提供6.30亿美元。它将首先关注拉沙热、尼帕病毒和中东呼吸综合征,它的目标是将有希望的疫苗从研发的炼狱中拉出来,推动它们通过试验,并将它们储存在成千上万的人身上。(一个目标是避免重蹈2014年的覆辙,当时埃博拉病毒肆虐西非,而一种可能阻止埃博拉病毒的实验性疫苗则在冷藏库中煎熬了10年。)

More important, the coalition is looking to fund so-called platform technologies that could create a vaccine against any new virus far more quickly than can be done today: within 16 weeks of its discovery. Most current vaccines work by presenting the immune system with dead, weakened, or fragmented microbes. Every microbe is unique, so every vaccine must be unique, which is one reason they’re so time-consuming to create. But by loading key parts of a given microbe onto a standard molecular chassis, scientists could build plug-and-play vaccines that could be swiftly customized.

更重要的是,该联盟正在寻求资助所谓的平台性技术,这些技术可以比今天更迅速地制造出一种针对任何新病毒的疫苗——在发现后的16周时间里。目前大多数的疫苗都是通过将免疫系统暴露在死亡、削弱或分裂的微生物面前来工作的。每一种微生物都是独一无二的,所以每一种疫苗都必须是独一无二的,这也是它们如此耗时的原因之一。但是,通过将特定微生物的关键部分加载到标准的分子底盘上,科学家们可以制造出可以快速定制的即插即用疫苗。

In the same way that movable type revolutionized printing by allowing people to rapidly set up new pages without carving bespoke woodblocks, such vaccines could greatly accelerate the defense against emerging infections. In 2016, a team of researchers used the concept to create a vaccine against Zika that is now being tested in clinical trials across the Americas. The process took four months—the shortest development time in vaccinology’s 222?year history.

就像活字印刷术通过允许人们快速构建新页面而不去雕刻定制的木板一样,这种疫苗可以极大地加速抵御新出现的传染病的能力。2016年,一组研究人员利用这一概念制造了一种针对寨卡病毒的疫苗,目前它正在美洲各地的临床试验中进行测试。这个过程花了四个月的时间——这是疫苗学222年历史上最短的研发时间。

The possibilities of vaccine science—a universal flu vaccine, plug-and-play platforms—are exciting. But they are only possibilities. No matter how brilliant and dedicated the people involved, they face a long and uncertain road. Missteps and failures are assured along the way; dogged effort and consistent support are essential to sustain the journey. These latter necessities, unavoidably, bring us to politics—where they are, predictably, in short supply.

疫苗科学的这种可能性——一种通用的流感疫苗,即插即用的平台——是令人兴奋的。但它们只是可能性。不管参与其中的人多么聪明,多么专注,他们都面临着一条漫长而不确定的道路。在这个过程中,失误和失败是肯定的;顽强的努力和持续的支持对维持这段旅程至关重要。这些必然性不可避免地把我们带到了政治问题之中——可以预见的是,它们的供应是不足的。

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There surely will be, though. At some point, a new virus will emerge to test Trump’s mettle. What happens then? He has no background in science or health, and has surrounded himself with little such expertise. The President’s Council of Advisers on Science and Technology, a group of leading scientists who consult on policy matters, is dormant. The Office of Science and Technology Policy, which has advised presidents on everything from epidemics to nuclear disasters since 1976, is diminished. The head of that office typically acts as the president’s chief scientific consigliere, but to date no one has been appointed.

不过,之后肯定会有的。在某种程度上,到时候将会出现一种新的病毒来考验特朗普的勇气。然后会发生什么呢?他没有科学或健康方面的背景,而且几乎没有这样的专业知识。总统的科学技术顾问委员会则是由一群围绕政策问题进行磋商的重要科学家组成的,它目前处于休眠状态。自1976年以来,科学与技术政策办公室一直为各位总统提供从流行病到核灾难等各种问题的建议。该办公室的负责人通常担任总统的首席科学顾问,但迄今为止还没有人得到任命。

Other parts of Trump’s administration that will prove crucial during an epidemic have operated like an Etch A Sketch. During the nine months I spent working on this story, Tom Price resigned as secretary of health and human services after using taxpayer money to fund charter flights (although his replacement, Alex Azar, is arguably better prepared, having dealt with anthrax, flu, and sars during the Bush years). Brenda Fitzgerald stepped down as CDC director after it became known that she had bought stock in tobacco companies; her replacement, Robert Redfield, has a long track record studying HIV, but relatively little public-health experience.

特朗普政府的其他部门在疫情中被证明是至关重要的,但它的运作方式就像蚀刻素描一样。在我花了9个月时间研究这个故事的过程中,汤姆·普赖斯在使用纳税人的钱为包机提供资金后辞去了卫生和公众服务部部长的职务(尽管他的继任者亚历克斯·阿扎尔在布什执政期间曾处理过炭疽、流感和非典型肺炎)。在她购买了烟草公司的股票的事情被曝光后,布兰达·菲茨杰拉德辞去了疾病防控中心主任的职位;她的继任者罗伯特·雷德菲尔德在研究艾滋病方面有着长期的记录,但其公共卫生经验却相对缺乏。

Rear Admiral Tim Ziemer, a veteran malaria fighter, was appointed to the National Security Council, in part to oversee the development of the White House’s forthcoming biosecurity strategy. When I met Ziemer at the White House in February, he hadn’t spoken with the president, but said pandemic preparedness was a priority for the administration. He left in May.

海军少将蒂姆?齐默是一名经验丰富的疟疾斗士,他被任命为国家安全委员会成员,这在一定程度上是为了监督白宫即将实施的生物安全战略的制定过程。今年2月,当我在白宫见到齐默时,他并没有与总统交谈,但他说,大流行预防是政府的首要任务。他在五月份离职了。

Organizing a federal response to an emerging pandemic is harder than one might think. The largely successful U.S. response to Ebola in 2014 benefited from the special appointment of an “Ebola czar”—Klain—to help coordinate the many agencies that face unclear responsibilities. In 2016, when Obama asked for $1.9 billion to fight Zika, Congress devolved into partisan squabbling. Republicans wanted to keep the funds away from clinics that worked with Planned Parenthood, and Democrats opposed the restriction. It took more than seven months to appropriate $1.1 billion; by then, the CDC and NIH had been forced to divert funds meant to deal with flu, HIV, and the next Ebola.

组织联邦政府应对新出现的流行病要比人们想象的要困难得多。2014年,美国对埃博拉病毒的反应基本上是成功的,这要受益于“埃博拉沙皇”——克兰——被特别任命来帮助协调许多面临不明确责任的机构。2016年,当奥巴马要求拨发19亿美元抗击兹卡病毒时,国会陷入了党派纷争。共和党人希望将这些资金从与美国计划生育联合会的诊所中分离出来,而民主党人则反对这一限制。最终花了七个多月时间才拨付了11亿美元;而到了那个时候,美国疾病控制中心和国家卫生研究所已经被迫将资金转移用于应对流感、艾滋病毒和下一波的埃博拉病毒。



Ron Klain was appointed the “Ebola czar” by President Obama in 2014 to provide speed and order to a federal response that required many agencies and was marked by unclear lines of responsibility. (Jonno Rattman)

2014年,罗恩·克兰被奥巴马总统任命为“埃博拉沙皇”,为联邦政府的应对行动保障速度和秩序,这一要求需要许多机构的参与,并以不明确的责任线为标志。

How will Trump manage such a situation? Back in 2014, he called Obama a “psycho” for not banning flights from Ebola-afflicted countries, even though no direct flights existed, and even though health experts noted that travel restrictions hadn’t helped control sars or H1N1. Counterintuitively, flight bans increase the odds that outbreaks will spread by driving fearful patients underground, forcing them to seek alternative and even illegal transport routes. They also discourage health workers from helping to contain foreign outbreaks, for fear that they’ll be denied reentry into their home country. Trump clearly felt that such Americans should be denied reentry. “KEEP THEM OUT OF HERE!” he tweeted, before questioning the evidence that Ebola is not as contagious as is commonly believed.

特朗普将如何处理这样的情况?早在2014年,他就称奥巴马是一个“精神病患者”,因为他没有禁止来自埃博拉疫情国家的航班,尽管当时并没有直飞航班,尽管卫生专家指出旅行限制无法帮助控制非典或H1N1病毒。与直觉相反的是,飞行禁令将增加疾病暴发传播的几率,迫使恐惧的病人转入地下,迫使他们寻找替代性的甚至非法的旅行路线。它还将挫败卫生工作者帮助控制外国疫情的热情,因为他们担心自己会被拒绝重新进入他们的祖国。特朗普显然认为,这样的美国人应该被拒绝再次入境。在质疑埃博拉病毒不像人们通常认为的那样具有传染性的证据之前,他在推特上写道:“让他们离开这里!”

Trump called Obama “dumb” for deploying the military to countries suffering from the Ebola outbreak, and he now commands that same military. His dislike of outsiders and disdain for diplomacy could lead him to spurn the cooperative, outward-facing strategies that work best to contain emergent pandemics.

特朗普称奥巴马是“愚蠢的”,因为他将军队部署到受埃博拉疫情影响的国家,现在他指挥着同样的军队。他对局外人的厌恶和对外交的蔑视,可能会导致他摒弃合作的对外战略,而这些策略却能够最有效地控制突发的流行病。

Perhaps the two most important things a leader can personally provide in the midst of an epidemic are reliable information and a unifying spirit. In the absence of strong countermeasures, severe outbreaks tear communities apart, forcing people to fear their neighbors; the longest-lasting damage can be psychosocial. Trump’s tendency to tweet rashly, delegitimize legitimate sources of information, and readily buy into conspiracy theories could be disastrous.

也许一个领导者在流行病中能够亲自提供的两件最重要的事情是可靠的信息和统一的精神。在缺乏强有力的应对措施的情况下,严重的疫情将使得社区分裂,迫使人们害怕他们的邻居;最持久的伤害可能是心理社会方面的。特朗普倾向于轻率地发布推文,将合法的信息来源非法化,并欣然接受阴谋论,这可能是灾难性的。

Emery Mikolo greets me warmly, with one outstretched hand. We shake, do a little ankle tap, and say, “Nous sommes ensemble”—“we are together.” This is the greeting of the Kikwit Ebola Survivors’ Association, of which Mikolo is a co-founder and the vice president. Fifteen of the 42 members file into the breakfast room of Hotel Kwilu, the men in simple shirts and the women in glorious kaleidoscopic dresses. The youngest are in their mid-30s, the oldest in their late 70s.

埃默里·米卡洛热情地伸出一只手向我打招呼。我们握了握手,轻拍了一下,然后说:“我们团结一致”。这是基奎特埃博拉幸存者协会的问候语,米卡洛是该协会的联合创始人和副主席。42名成员中有15人进入了奎卢酒店的早餐室,其中有穿着简单衬衫的男人和穿着华丽的万花筒式服装的女人。这些人中最年轻的有30多岁,年纪最大的则有70多岁。

There is still no definitive treatment for Ebola. In 1995, like most of the survivors, Mikolo fought the virus off on his own, over three grueling weeks. After he recovered, he donated his blood—and the virus-fighting antibodies within it—to others, saving the lives of Shimene Mukungu and Emilienne Luzolo, who are also here today. Blood spreads Ebola. Sometimes, blood cures it.

目前还没有针对埃博拉的明确治疗方法。在1995年,和大多数幸存者一样,米卡洛在三周的时间里独自对抗着这种病毒。在他康复后,他将自己的血液——以及其中的病毒抗体——捐赠给了其他人,拯救了穆昆古和埃米利安·卢佐洛的生命,他们今天也在这里。血液传播埃博拉病毒。有时,血液也治愈了它。

The outbreak destroyed entire families. Afterward, some of the survivors found themselves the sole providers for several children. Others were orphans. Worst of all, they became pariahs. “Here, for we who live in communities, it is solitude that kills us,” Mikolo says. He rolls up his trouser leg and shows me the scars inflicted by fearful neighbors, who hurled stones at him when he tried to return home. Like others, he discovered that his house and belongings had been burned.

爆发的疫情摧毁了整个整个的家庭。之后,一些幸存者发现自己是几个孩子的唯一抚养者。其他人则都是孤儿。最糟糕的是,他们变成了贱民。“在这里,对于我们这些生活在社区的人来说,孤独会让我们死亡,”米卡洛说。他卷起裤腿,向我展示了可怕的邻居们给他留下的伤疤,当他试图回家时,他们向他扔石头。和其他人一样,他发现他的房子和财产都被烧毁了。



Emery Mikolo in March 2018 in Pavilion 3, which housed Kikwit’s Ebola patients in 1995 and is now a pediatrics ward (Ed Yong)

埃默里·米克罗于2018年3月在3号病房楼,1995年基奎特的埃博拉患者都居住在这里,现在这里是儿科病房

The survivors banded together. “We had to take care of ourselves,” Norbert Mabanza, the association’s president, tells me. “Those with a little bit of strength could support those who were weaker. Débrouillez-vous.”

幸存者联合了起来。“我们必须照顾好自己,”协会主席诺伯特·马般扎告诉我。“那些有一点力量的人可以支持那些弱者。自己去解决吧。”

I listen to their stories in the company of Anne Rimoin, an epidemiologist from UCLA. During her 16 years working in the Congo, Rimoin has shown that monkeypox is on the rise, helped discover a new virus, and worked to create the first truly accurate maps of the country, down to the most-isolated villages. The Congo is a second home for her. When Rimoin’s father died shortly before her wedding, Muyembe, the virologist who first encountered Ebola, flew to Los Angeles to walk her down the aisle.

我在加州大学洛杉矶分校的流行病学家安妮·里穆瓦的公司里听到了他们的故事。在里穆瓦在刚果工作的16年里,她发现猴痘发病率正在增加,并帮助发现了一种新的病毒,并致力于创造出第一幅真正精确的国家地图,其中甚至包括了最孤立的村庄。刚果是她的第二个家。当里穆瓦的父亲在她的婚礼前不久去世的时候,第一次接触埃博拉病毒的病毒学家穆延贝飞到了洛杉矶,陪她走过红毯。

Rimoin emphasized to me the social rupture that disease outbreaks wreak on unprepared communities, and the difficulty of repair. She also said that until the Congo and other developing countries can control the diseases at their doorsteps, it is imperative for richer nations like the United States to help them. That was a truth acknowledged by every expert I spoke with: The best way to prevent pandemics is to contain outbreaks at their source. The U.S. cannot possibly consider itself protected if other nations are not.

里穆瓦向我强调了疾病暴发对没有准备的社区造成的社会破裂,以及修复的困难所在。她还说,在刚果和其他发展中国家能够在家门口控制这些疾病之前,像美国这样的富裕国家必须帮助它们。这是我采访过的每一位专家都承认的事实:预防流行病的最好方法是在源头控制疫情。如果其他国家没有得到保护,美国不可能自认为安全无虞。

America’s prior investments in global health preparedness—the largest of any nation’s—have already made a tangible difference. In 2010, the CDC helped Uganda set up a new surveillance system for viral hemorrhagic fevers like Ebola and Marburg. Health workers there are now trained to recognize these diseases, and have tools for collecting samples safely. Labs have diagnostic equipment. Response teams are ready to go. “It’s been incredible to watch,” says Inger Damon, who oversaw the CDC’s 2014 Ebola response. “It used to take two weeks to respond to an outbreak. By the time you understood what was going on, you’d have 20 to 30 cases, and eventually hundreds. Now they can respond in two days.” Sixteen outbreaks have been detected since 2010, but they were typically much smaller and shorter than before. Half of them involved just one case.

美国之前对全球卫生准备的投资——这是所有国家中最大的——已经产生了切实的影响。2010年,美国疾病控制中心帮助乌干达建立了一个用于病毒性出血热——如埃博拉病毒和马尔堡病毒——的新的监测系统。那里的卫生工作者现在已经接受了识别这些疾病的训练,并且有了安全的收集样本的工具以及实验室诊断设备。反应小组已经做好了准备。“这是令人难以置信的,”负责美国疾病防控中心2014年埃博拉应对工作的林格达蒙说道,“过去需要两周时间来应对疫情。当你明白发生了什么事的时候,你会碰到20到30个病例,最终会有几百个病例。现在他们可以在两天内做出反应。”自2010年以来,它已经监测了16次疫情,但它们的规模通常比以前小得多,也更短。其中一半的疫情只涉及到一个病例。

And in July 2014, in the midst of the West African Ebola outbreak, those investments very likely prevented a horrific catastrophe that might otherwise still be unfolding today. A Liberian American man brought the virus into Lagos, Nigeria, home to 21 million people and one of Africa’s busiest airports. “If it had gone out of control in Lagos, it would have gone all over Africa for years,” Tom Frieden, the former CDC director, says. “We were right on the edge of the abyss.”

2014年7月,在西非埃博拉疫情爆发期间,这些投资很有可能阻止了一场可能到今天仍在上演的可怕灾难。一名利比里亚裔美国人将病毒带到了尼日利亚的拉各斯,那里有2100万人,也有着非洲最繁忙的机场之一。“如果它在拉各斯失去控制,它将在整个非洲蔓延多年,”前疾控中心主任汤姆弗里登说,“我们就处在深渊的边缘。”

But Nigeria responded quickly. For years, it had used investments from the U.S. and other countries to build infrastructure for eradicating polio. It had a command center and a crack team of CDC-trained epidemiologists. When Ebola hit Lagos, the team dropped its polio work. It found every person who’d contracted Ebola, and every person with whom those infected had had contact. In only three months, after just 19 cases and eight deaths, it brought Ebola to heel and stopped it from spreading to any other country.

但尼日利亚迅速做出了回应。多年来,它一直利用来自美国和其他国家的投资来建设根除小儿麻痹症的基础设施。它有一个指挥中心和一个由美国疾病控制中心训练的流行病学家组成的团队。当埃博拉病毒袭击拉各斯时,该小组放弃了脊髓灰质炎的工作。它发现了每一个感染了埃博拉病毒的人,以及每一个与感染者有过接触的人。仅仅三个月后,在仅仅出现了19个病例和8个死亡病例之后,它就把埃博拉病毒根除了,并阻止了它向其他国家的传播。

With patience and money—not even very much money compared with the vastness of rich-country spending—this kind of victory could be commonplace. An international partnership called the Global Health Security Agenda has already laid out a road map for nations to plug their vulnerabilities against infectious threats. Back in 2014, the U.S. committed $1 billion to the effort over five years. With it came a clear, if implicit, statement: Pandemic threats should be a global priority. Nous sommes ensemble.

有了耐心和金钱——与富裕国家的巨额支出相比,甚至这不算很多钱——这种胜利可能就是司空见惯的。一个名为“全球卫生安全议程”的国际伙伴关系已经为各国制定了一份路线图,让各国能够弥补自己的薄弱环节,对抗传染病的威胁。早在2014年,美国就承诺在5年内投入10亿美元。随之而来的是一项明确且含蓄的声明:流行病威胁应该是全球优先考虑解决的问题。我们团结一致。

Given that sense of commitment, and with the related funding in hand, the CDC made a large bet: It began helping 49 countries improve their epidemic preparedness, on the assumption that demonstrating success would assure a continued flow of money. But that bet now looks uncertain. Trump’s budget for 2019 would cut 67 percent from current annual spending.

考虑到这种承诺,以及相关的资金投入,疾病防控中心下了一个大赌注:它开始帮助49个国家改善他们的流行病预防工作,前提是证明这种成功将确保资金的持续流动。但现在看来,这种押注似乎是失败的。特朗普2019年的预算将会把目前的年度支出削减67%。

If investments start receding, the CDC will have to wind down its activity in several countries, and its field officers will look for other jobs. Their local knowledge will disappear, and the relationships they have built will crumble. Trust is essential for controlling outbreaks; it is hard won, and not easily replaced. “In an outbreak, there’s so little time to learn things, make connections, learn how to not offend people,” Rimoin tells me. “We’re here in the Congo all the time. People know us.”

如果投资开始减少,美国疾病控制与控制中心将不得不减少在几个国家的活动,而它的现场工作人员也会去寻找其他工作。他们对于当地的知识将会消失,他们所建立的关系将会崩溃。信任对于控制疫情至关重要;这是来之不易的,不易被取代的。里穆瓦告诉我:“在疫情爆发时,几乎没有时间去学习,建立联系,学习如何不冒犯别人。我们一直都在刚果。人们知道我们。”

Until Rimoin arrived in Kikwit last summer, the Ebola survivors had for decades refused to collaborate with outsiders. “Others see us as people to study,” Mikolo tells her. “But you came to us with friendship and humanity. You haven’t abandoned us.” Indeed, while Rimoin is studying the blood of the survivors, she is also trying to set up a clinic where survivors, half of whom are medically trained, can provide primary care to one another and to their communities. She has used donations and some of her own money to help Mabanza, the association’s president, get a master’s degree in public health.

直到去年夏天里穆瓦抵达基奎特之前,埃博拉幸存者几十年来一直都拒绝与外界合作。“其他人把我们看作是研究的标本,”米卡洛告诉她,“但你是带着友谊和人性来到我们这里的。你没有放弃我们。”的确,当里穆瓦研究幸存者的血液的同时,她也在试图建立一个诊所,在那里,幸存者——其中一半接受过医学培训——可以为彼此和他们的社区提供初级保健。她用募得的捐款和一些自己的资金来帮助该协会的主席马般扎获得公共卫生的硕士学位。

Rimoin and I take the same flight out of Kinshasa; she will likely be back in a few months. I think about her ties to the Congo as our plane soars over one of the most biodiverse rain forests in the world. Below my flight path, the sparks of a new Ebola outbreak are flickering, unbeknownst to me or any of the scientists with whom I’d spoken. (It would be discovered in the weeks that followed.)

里穆瓦和我乘坐同一架飞机离开金沙萨;她很可能在几个月后回来。我想到了她与刚果的关系,因为我们的飞机飞越了世界上最具生物多样性的热带雨林之一。在我的飞行路径下,一场新的埃博拉疫情爆发的火花正在闪耀,而我和我所交谈过的任何科学家都不知道这一点。(它将在随后的几周内被发现。)

I think about the survivors of Kikwit, and how our connectedness is both the source of our greatest vulnerability and the potential means of our salvation. I think about whether it is possible to break the old cycle of panic and neglect, to fully transition from Débrouillez-vous to Nous sommes ensemble. I think about this amid bouts of restless sleep, as the plane flies westward across the Atlantic, stuck in the shadow of the world, until finally, dawn catches up.

我想到了基奎特的幸存者,以及我们的联系如何成为我们最大的弱点的来源和我们的救赎的潜在手段。我想,是否有可能打破旧的恐慌和忽视的循环,从“自己去解决吧”到“我们团结一致”。我在辗转的睡眠中想到这一点,而飞机正在向西飞越大西洋,此时的大西洋正蜷缩于这个世界的阴影里,直到最后,黎明赶了上来。