The Pandemic That's Already Here

Picture this: it's Fourth of July weekend, America's 250th birthday. A patient walks into a Washington, D.C., emergency room. International traveler. Initially mild symptoms. Then, the standard medications stop working. Not because the diagnosis was wrong — but because the bacteria causing the infection have evolved past the drugs we have to fight them. A nurse mentions it to a friend who happens to be a reporter. Within hours, garbled TikTok videos are describing a mystery illness spreading from the National Aquarium to a restaurant in Old Town Alexandria.

 That scenario isn't fiction. It was the opening of a tabletop exercise I participated in just last week. And the reason it lands so hard in the room is that everyone in it knows: this is not a hypothetical. It is a live possibility, on any given day, in any emergency room in America.

 Antibiotic resistance isn't coming. It's here. And we are losing.

The invisible pandemic doesn't get an outbreak photo

 Part of why this crisis generates so little political urgency is structural. A respiratory virus moving between people produces dramatic images: overwhelmed hospitals, refrigerated morgue trucks, panic buying. Antibiotic resistance produces none of that. It manifests as an elderly woman with a urinary tract infection who isn't responding to the usual pills. A cancer patient whose post-chemotherapy infection won't clear. A transplant recipient dying of a bloodstream infection that, twenty years ago, would have been a footnote.

 Each case looks like an individual tragedy. In aggregate, it's a catastrophe.

 Drug-resistant infections kill tens of thousands of Americans every year. Globally, bacterial AMR was directly responsible for 1.27 million deaths in 2019 alone, with another 4.95 million deaths associated with it. A 2024 Lancet study projects that figure rising to 1.91 million deaths annually by 2050, with 39 million people expected to die from drug-resistant infections between 2025 and 2050.

 That is akin to a pandemic by any reasonable definition. We just haven't conceptualized it that way.

Resistance is natural. The crisis is not.

Antibiotic resistance doesn't require humans. It predates us by billions of years. Bacteria have been fighting each other with chemical weapons — and evolving defenses against those weapons — for as long as life has existed on Earth. Resistance genes have been found in underground cave-dwelling bacteria that have never once been exposed to human civilization. We didn't create the problem. We accelerated it to the point of crisis.

 When Alexander Fleming noticed that mold was killing the bacteria in his Petri dish in 1928 — and when Howard Florey and Ernst Chain turned that observation into actual medicine a decade later — they had no idea they were also starting a clock. Every antibiotic that enters the human body exerts selective pressure on bacteria: the organisms that happen to have resistance mechanisms survive; the others don't.

 Do that across billions of courses of antibiotics, billions of animals in agriculture, and decades of sloppy stewardship, and you predictably accelerate what was always going to happen eventually.

At first glance, antibiotic resistance can seem like an inevitable story of decline.

None of this means antibiotics were a failure. Quite the opposite. Resistance is the expected consequence of evolution acting on bacterial populations. The remarkable achievement was never that penicillin worked forever. The achievement was that human beings discovered penicillin in the first place. The same capacity for reason that uncovered the antibiotic era can build whatever comes next. The danger is not that bacteria adapt. The danger is that our institutions, incentives, and investments stop adapting faster than they do.

What makes this crisis acute right now: the resistance is (predictably) winning, and the pipeline of new antibiotics has nearly run dry.

One data point that should give you pause: NDM — New Delhi metallo-beta-lactamase, a resistance enzyme that makes bacteria nearly impervious to our most powerful class of antibiotics — used to be rare in the U.S., found in just 5.4% of resistant E. coli cases. That number is now 39.3%. It moved from "rare import" to "common problem" in a generation. And it's being driven by factors we're not fully controlling: over-the-counter antibiotics freely available in much of the world, antibiotics prescribed for viral sinusitis, for herniated discs (which are not bacterial infections), for asthmatic children whose flares are almost always viral. Environmental factors — rainfall, temperature — even appear to correlate with resistance rates. Many forces are pushing in the same direction at once.

 Modern medicine depends on antibiotics the way a building depends on its foundation

 The thing people miss when they think about antibiotic resistance is this: it isn't just about infections. It's about the entire architecture of modern medicine.

A hip replacement, a coronary bypass, an appendectomy — every one of these routine procedures requires antibiotic prophylaxis to prevent infection during and after surgery. When you give a cancer patient chemotherapy, you deliberately suppress their immune system to kill tumors, and then you rely on antibiotics to protect them from infections their body can no longer fight. Organ transplantation requires immune suppression for life. Neonatal intensive care, premature birth management, burn treatment — all of it rests on the assumption that if a bacterial infection arises, it can be beaten.

 Remove that calculus, and you lose more than the ability to treat infections. Much of what we call modern civilization depends on a medical system that assumes bacterial infections remain controllable. You lose the ability to do most of modern medicine. You are returned, in the most important functional sense, to the pre-penicillin world — where a simple laceration could mean death and the operations we now perform routinely were the stuff of science fiction.

Market disincentives broke antibiotics before resistance could

 The antibiotic pipeline isn't primarily empty because scientists stopped trying. It's empty because of a market dynamic so structurally strange that it's almost elegant in how badly it's constructed.

 Every other drug that gets developed follows a simple enough commercial logic: you discover a molecule that treats a disease, get it approved, and sell it. The more patients who need it, the more revenue you generate. That logic completely breaks down for antibiotics.

 First, antibiotic courses are short — days to weeks, not lifetime prescriptions. Less time on therapy means less revenue per patient. Second, resistance makes new antibiotics obsolete over time, eroding whatever market you've built. Third — and this is the truly unique part — the pharmaceutical company is actively punished for successful adoption of their drug. The more widely a new antibiotic is used, the faster resistance develops, and the sooner it stops working. So responsible doctors and health systems try to steward the use of the best new antibiotics, reserving them as drugs of last resort. That means the drugs that work best and are most valuable are the ones you sell the fewest of — the exact opposite of every other product in medicine.

These market factors have produced predictable consequences: major antibiotic manufacturers like Melinta and Achaogen have gone bankrupt in recent years. In 2025, there were only 90 antibiotic candidates in development globally — compared to over 2500 in oncology. Companies have simply stopped trying.

 The fix exists. It's called the PASTEUR Act. It keeps dying in committee.

 The solution to this situation has been identified. It is not complicated in concept, even if it's politically hard to pass.

 The logic is simple: decouple how much a pharmaceutical company is paid from how much of their antibiotic is actually used. Instead of revenue tied to volume — which punishes responsible stewardship — the government would pay a subscription fee for access to a portfolio of antibiotics targeting the most dangerous resistant pathogens. Think of it like a Netflix model: you pay for the service regardless of how many episodes you watch. The antibiotic company gets a predictable revenue stream that doesn't collapse just because doctors are correctly reserving their drug for the worst cases.

 This is what the PASTEUR Act — the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance Act — is designed to do. It has been introduced, reintroduced, and reintroduced again. First introduced it in 2020, a new version was reintroduced in the Senate on June 24th of this year, with bipartisan co-sponsors.

 And there it sits. Again.

 The reason this keeps stalling is a separate cultural problem worth naming directly: as a society, we have somehow decided that antibiotics should be cheap. This is a historical accident. Antibiotics were first developed in an era when drug discovery was cheap and drug pricing was in its infancy. That pricing norm got locked in, and it's never been seriously revisited. Nobody protests when we spend $475,000 on a course of CAR-T therapy to treat leukemia. But the moment a new antibiotic carries a price tag that reflects its actual development cost, the political instinct is to accuse the manufacturer of price gouging. Ezekiel Emanuel put it plainly: "As a society, we seem willing to pay $100,000 or more for cancer drugs that cure no one and, at best, add weeks or a few months to life. So why won't we pay $10,000 for a lifesaving antibiotic?"

The answer is cultural, not scientific. And until we fix the culture, the PASTEUR Act will keep getting reintroduced and keep stalling.

The DISARM Act targets the other end of the same problem. Under Medicare's current bundled payment system, hospitals actually lose money when they use newer, more expensive antibiotics — so the financial incentive is to keep reaching for older, cheaper drugs even when resistance has made those drugs less effective. DISARM would carve out a separate reimbursement track for qualifying antibiotics, so hospitals aren't penalized for doing the right clinical thing.

Beyond conventional antibiotics

 Even if we pass the PASTEUR and DISARM Acts tomorrow — and we should — conventional antibiotics alone cannot win this war in the long run. The resistance genes are older than civilization. They will always exist somewhere in the environment, waiting to be selected for. An arms race built entirely on finding new versions of existing weapons is a race we can never win outright.

 That's why the most exciting work in this space isn't happening in traditional antibiotic discovery. It's happening in adjacent technologies: monoclonal antibodies that target specific bacteria or their toxins without touching the microbiome; bacteriophages — viruses that naturally hunt and kill specific strains of bacteria, deployed therapeutically against infections that no antibiotic can clear; microbiome-based therapies that restructure the bacterial ecosystem in a way that crowds out dangerous pathogens; CRISPR-based tools that could theoretically delete resistance genes from bacteria directly. None of these are fully ready for prime time.

This is the real moonshot. Not finding one more antibiotic that buys us another decade. Building a fundamentally different toolkit that doesn't depend on a chemical arms race we are structurally losing.

 What the tabletop exercise taught me

 Back to that Washington emergency room. In the scenario, the question that got the sharpest debate wasn't the clinical one — what drug do you try? It was the cascade question: when does an individual patient become a public health emergency? When does a public health emergency become a national security threat?

 The answer I kept coming back to: antibiotic resistance is already a national security threat. It threatens far more than individual patients. Modern military medicine depends on effective antibiotics to treat combat wounds, burns, and trauma-related infections. Disaster response systems assume that bacterial infections can be controlled after hurricanes, earthquakes, and mass casualty events. Preparedness plans for biological attacks rely on antibiotics as a core layer of defense. A future in which common pathogens routinely outpace available treatments is not simply a public health problem; it is a direct challenge to national resilience and national security.

It just doesn't look like a national security threat because there's no single outbreak photo, no patient zero tracked across continents, no dramatic escalation moment. It's the slow erosion of the foundation that everything else stands on — surgery, chemotherapy, transplantation, neonatal care — happening in every hospital, in every country, simultaneously, without anyone formally declaring an emergency.

 The technology to reverse this trajectory and master this problem exists. The scientific problem is difficult but solvable. The political problem is deciding that it matters.

The legislation to fix the pipeline has been written, rewritten, and introduced. What's missing is the sustained political will to treat this as the crisis it is — not a wonky reimbursement problem to be handled in committee, but the slow-motion unraveling of the medical gains that define the difference between the world we live in and the world that Fleming found when he went to work in the morning.

We have the toolbox. We are choosing not to use it. That is a decision we are making, not a fate being visited upon us.

Measles is the Default

(I’ve adapted this piece’s title from Dr. Gena Gorlin’s excellent essay arguing that for human beings, death is the default.)

Recently, I was listening to psychologist Steven Pinker discuss the Second Law of Thermodynamics on a panel. Entropy, in its broadest sense, describes the tendency of systems toward disorder. Pinker noted that human agency acts as a countervailing force, creating pockets of order in a universe that naturally trends in the opposite direction.

I’ve been thinking about that idea a great deal lately, particularly in the context of what I see as the role of infectious disease physicians, nurses, physician assistants, nurse practicioners, epidemiologists, virologists, microbiologists, infection control practitioners, as defenders of civilization.

Transposed into the realm of infectious disease, entropy means that death, disability, and disruption caused by infectious agents are the norm. Human beings altered that trajectory through reason. Germ theory, sanitation, antisepsis, vaccination, antibiotics, antiviral drugs, and modern public health infrastructure are all products of human intelligence directed toward a specific purpose: creating order where nature provided none. Left unattended, the natural trajectory is not toward health but toward recurring outbreaks, epidemics, and premature death.

Measles is the default.

For most of human history, measles infected everyone. Measles elimination was not the natural state of the world. It is an achievement.

And like all achievements, it requires maintenance.

Civilization itself is not automatic. It must be continuously maintained and advanced. Societies can and do backslide. The Dark Ages remain the most famous example. I often think of the Antikythera mechanism—a sophisticated ancient Greek device whose purpose was lost for centuries. Imagine discovering such an object in the Dark Ages, possessing the artifact but lacking the intellectual framework necessary to understand it because people jettisoned that framework.

History offers many examples of achievements that were abandoned, forgotten, or allowed to deteriorate. The Concorde disappeared. Human moon missions ceased for decades. Today, vaccines are following a similar trajectory. A nightmare scenario is some future human finding a vial of an mRNA vaccine the way we first held the Antikythera mechanism—possessing the artifact but having lost the intellectual culture that made it possible.

Human flourishing consists of creating islands of order against a backdrop of entropy.

This is why the return of measles in the United States is not primarily a biological event. It is a cultural and intellectual one.

The measles virus has not become more virulent. The vaccine has not become less effective. What has changed is humans’ willingness to support the technology that made elimination possible.

The ultimate resource is not a vaccine, an antibiotic, an antiviral, or a hospital.

It is the human mind.

The same force that drained swamps, built sewers, created vaccines, developed antibiotics, eradicated smallpox, and eliminated measles is the force that keeps entropy at bay.

Measles elimination was not humanity’s inheritance. It was humanity’s achievement.

The state of nature is not measles elimination but measles endemicity.

The Bear and The Microbe

A grizzly bear weighs more than 1,000 pounds, can run faster than a racehorse, and possesses claws and teeth that make human beings look laughably ill-equipped for survival. Yet in The Edge, it is not the bear that ultimately demonstrates superiority. It is the human mind.

This movie, made decades ago, is something that I keep coming back to. I am drawn to this movie because of its theme — the edge that humans have over other species. The edge that enables us to thrive in a natural world that is often hostile. That edge is not an opposable thumb but our specific consciousness which houses the faculty of reason. It is reason that allows humans to shape the world in a manner that is conducive to human survival, beating back lions, tigers, wolves, floods, hurricanes, and — critically — infectious diseases. It is also the case that the knowledge discovered by one human mind can be acquired by another, creating a web of information flow that serves to promote human life beyond the temporal and spatial bounds it was discovered in.

The Edge is fundamentally about thinking and using one’s mind to solve problems related to survival. In the film, a group of men are stranded in the wilderness. However, it is not the physically strongest human that flourishes but the one most committed to the use of reason. As they square off against the elements and the superior physical prowess of bears, it is the mind that triumphs.  This is not surprising. As the philosopher Ayn Rand identified, and the film dramatizes, reason is man’s means of survival.

Darwin understood that humanity’s distinctive adaptation was not speed, strength, claws, or teeth. It was intelligence. Reason, he wrote, stands “at the summit” of mankind’s mental faculties. Humans survive not by adapting themselves to every environment, but by adapting the environment to themselves.

As such, it is the human capacity to reason that stands as the ultimate resource to call upon for survival issues.

These survival issues most definitely extend beyond bears. The bear in The Edge is simply a stand-in for nature’s threats. For most of human history, those threats included yellow fever, smallpox, cholera, plague, tuberculosis, and influenza and only in recent generations have some humans secured freedom from the disruption, death, and despair that characterizes infectious disease outbreaks.

The story of infectious disease is the story of reason applied to nature. Smallpox did not disappear because nature became kinder. Cholera was not defeated because rivers became cleaner. Yellow fever did not retreat because mosquitoes became less dangerous.

Human beings identified causes, discovered mechanisms, tested hypotheses, and transformed knowledge into action. Every vaccine, antibiotic, sanitation system, intensive care unit, and genomic surveillance network is reason made tangible.

Left to her own devices, Mother Nature would kill us. Survival rdepends on the ability to think. It is not automatic; it is an achievement. The edge that separates humanity from the bear, the mosquito, and the microbe is ultimately the same edge dramatized in the film: the reasoning mind.

If You Want to Be a Real Darwinist, You Vaccinate

“There is reason to believe that vaccination has preserved thousands” — Charles Darwin

An argument that impacted how I think about vaccination happened not in a clinic or a hospital, but on a boat near the Galápagos Islands, where a naturalist guide told me that humans shouldn't try to modify their lives in ways that interfere with natural selection.

He meant it as wisdom. He was wrong, and Darwin himself would have told him so.

Darwin's most important sentence could be one you don’t know

Everyone knows Darwin for On the Origin of Species, published in 1859. But the book that reveals what he actually thought about human beings is The Descent of Man, published in 1871, where he turned his lens from finches and tortoises onto humans.

A sentence that should be far more famous than it is comes from Chapter III: "Of all the faculties of the human mind, it will, I presume, be admitted that Reason stands at the summit."

That sentence isn’t just a philosophical aside. He wrote it as an evolutionary statement. By The Descent of Man, Darwin had worked out what distinguished humans from every other species: not our size, not our strength, not our speed, not even our immune systems — but our capacity to reason. To form abstractions. To look at a pattern and induce a principle. To look at a virus and build a countermeasure. Darwin’s view of reason is that it is the means of survival for humans.

For Darwin, reason is not separate from natural selection but is natural selection's crowning project.

The Galápagos, of all places, is where this argument gets tested

I was standing in the place where Darwin assembled the observations that led him to his theory. Marine iguana, blue-footed Boobies, and the famous finches with their divergent beaks. And a guide — a naturalist, someone who had devoted his life to understanding this place — was telling me that when infectious disease shapes our species, we should let it.

I disagreed then, and I disagree now, on Darwin's own authority.

The guide's mistake was treating natural selection as something that happens to humans from the outside. But Darwin's argument was that reason itself is what natural selection built in us. When a virologist reads the genome of a novel coronavirus in January 2020 and a vaccine is in arms eleven months later, that isn't interference with Darwinian evolution. It's Darwinian evolution doing what it has been doing for millions of years: favoring the traits that help our species survive. Our trait is reason. Reasoning our way to vaccines. (Not by accident, Darwin’s view of reason was a topic I wrote a paper on in a favorite course I took in the 1990s as a post-baccalaureate student because I was so excited about the material: Jim Lennox’s Darwinism and its Critics at the University of Pittsburgh).

The anti-vaccine movement gets Darwin backwards

The "natural immunity is better" argument is an attempt at constructing a respectable-sounding voice of vaccine hesitancy. It has scientific adjacent clothing — it invokes evolution, selection pressure, immune memory and draws on real phenomenon. It sounds like Darwin.

It isn't. In fact, Darwin wrote: “There is reason to believe that vaccination has preserved thousands, who from a weak constitution would formerly have succumbed to small-pox.” Darwin recognized vaccination as a triumph of reason. Jenner looked at milkmaids and cowpox lesions and induced a principle from scattered observations. He saw a pattern in nature and converted it into a technology that liberated humanity from smallpox. 

 The people who make this argument are, implicitly, asking you to treat nature as a norm-setter, something Darwin’s quote about vaccines stands in opposition to.  As if what nature does to us without our intervention is what should happen — those with “a weak constitution” succumbing to smallpox. This is the naturalistic fallacy dressed in evolutionary costume: the idea that because something is natural, it is good, or at least better than the alternative.

But Darwin didn't believe nature was a norm-setter. He described a blind, indifferent mechanism that favors whatever survives. He recognized that vaccination, a product of human reason, is a countervailing force that emanated from Edward Jenner’s faculty of reason.  Nature’s mechanism, devoid of human intervention, produces outcomes that no sane person would call a design goal: the Black Death killing a third of Europe; the 1918 influenza killing 50 to 100 million people; malaria, operating as a Darwinian selection pressure on the human genome for so long that it left permanent marks.

Which brings me to the honest face of natural immunity: it is a real phenomenon that comes at a cost.

Natural selection’s solution to malaria is a blood disorder

Of all the things I've written about infectious disease, the malaria-sickle cell story is the one that most concretely illustrates what natural selection, left to its own devices, actually produces.

It is often said that malaria has killed roughly half of all humans who ever lived. The Plasmodium parasites that cause it have been killing humans for so long, and in such numbers, that they became a selection pressure — they began to shape our genome.

The result: a mutation that, in carriers who inherit one copy, confers resistance to malaria. Natural selection preserved it because carriers survived long enough to reproduce. But inherit two copies of the mutation, and you have sickle cell anemia — a painful, debilitating, life-shortening blood disorder.

That is what natural immunity looks like when it's working as designed. Nature's answer to one of history's most lethal pathogens was to introduce blood diseases into the human population as a consolation prize. You can see the geographic overlap precisely: superimpose a map of where malaria has historically been endemic with a map of where sickle cell anemia (and the other malaria-influenced blood diseases G6PD deficiency, thalassemia, and hereditary spherocytosis) is prevalent, and the lines match almost perfectly. Natural selection did this. Over thousands of years of uncountable death.

Contrast this with what reason did to malaria: DDT eliminated it from most of the industrialized world within decades. Artemisinin-based therapies transformed treatment. Insecticide-treated bed nets keep sleeping humans safe. Vaccines decrease deaths. Modified mosquitoes will add even more. The tools built by conscious minds are doing in years what blind selection couldn't accomplish in millennia — and without the blood disorder as a byproduct. Human reason is also addressing sickle cell anemia, natural selection’s deadly byproduct, with bone marrow transplants and gene therapies.

The mRNA vaccine is what reason built

The mRNA vaccine platform is one of the clearest contemporary illustrations of this I know. For decades, scientists worked on the basic science of messenger RNA — how to stabilize it, how to deliver it, how to get cells to read it as an instruction and produce a protein. The key breakthrough on the delivery mechanism came in the 1990s. The key breakthrough on mRNA stability — a modification to the nucleoside that makes up the molecule — came from Katalin Karikó and Drew Weissman, a discovery that eventually earned the 2023 Nobel Prize in Medicine (and a Time Magazine cover that adorns my wall). None of this was done in anticipation of a specific pandemic. It was basic science, driven by curiosity and the slow accumulation of knowledge.

When SARS-CoV-2 arrived, its genome was sequenced and published in January 2020, and within 11 months, a vaccine built on that entire accumulated foundation was authorized and in arms. The speed looked miraculous. It wasn't. It was what happens when reason suddenly has a problem needing a solution at maximum urgency.

I have been calling vaccines "liberation technology" for years. When humans refuse to accept hostile nature's terms, they create the means to master these problems, winning freedom for themselves from being helpless against nature’s machinations. 

The deeper point is Darwinian: we aren't refusing nature's terms. We are executing nature's terms. 

Nature built a species capable of this: us. When we use that capability, we aren't defying the process that made us. We are the process that made us.

What my Galápagos guide got wrong

The guide on that boat had a philosophy that sounds like reverence for nature but is actually a form of self-abnegation. He was asking members of the most cognitively sophisticated species in the history of the planet to suppress the faculty that makes them what they are, out of deference to a blind mechanism that, left to itself, produces sickle cell anemia and the Black Death.

Darwin would have found this baffling. The man who spent his life documenting the adaptive genius of natural selection understood that what it had built in us — above all else — was reason.

The anti-vaccine movement, in all its varieties, makes the same error as my guide. It mistakes nature for a moral authority. It treats "natural" as a synonym for "correct." It advocates letting disease do what it would have done before we had the capacity to stop it, on the theory that this is somehow more authentic to who we are.

But nothing is more authentic to who we are than thinking our way to a solution.

The real Darwinists vaccinate

There is a false version of Darwinism that concludes vaccines are interference.

Darwin's version —reason standing at the summit — concludes something quite different. It concludes that the species capable of reasoning its way out of the jaws of infectious disease is doing exactly what natural selection shaped it to do. That is the mRNA vaccine, developed from a genome sequence in under a year. It stands as one of evolution's most recent and most impressive outputs.

We have had 10,000 generations of humans. Only the last four have lived in a world where we can reliably master some infectious diseases. The tools that made that possible — vaccines, antimicrobials, diagnostics, sanitation — are the products of the one trait Darwin identified as the summit of what natural selection can build.

If you want to honor Darwin, don't retreat to nature's indifference. Use your mind. That's what Darwin said it was for.

Vaccinate. 

Civilization’s Vampire Slayers

I have always been fascinated by the macabre, the occult, and the mysterious. Maybe it was a form of psychological reactance as a Catholic school student from kindergarten to 8th grade? Vampires were always a favorite and I thought it was cool that I lived in Pennsylvania and there was a place with the same suffix called Transylvania that was part of vampire lore. I even climbed the 1400+ stairs of Poenari Castle in the Romanian Carpathian Mountains to see the ruins of what was, I imagine, an impenetrable fortress of Vlad the Impaler, Bram Stoker’s historical Dracula.

Long before microbes were understood, people often explained epidemics through monsters. Vampires, witches, curses, and demons were attempts to impose agency on otherwise mysterious illness.

The vampire is often associated with disease causing rats and bats. His Transylvanian soil required for travel can be “sterilized” with Eucharist wafers to force him to flee back to his home. Vampirism was also thought to be related to tuberculosis as individuals consumed by the disease were thought to be being consumed by vampires rising from coffins.

I’ve written about how I liken being an infectious disease physician to being akin to a Ghostbuster, Indiana Jones, a Man in Black, and an exorcist but it is also like being a vampire slayer.

When it comes to vampire slayers, there is only Buffy — and Faith. I absolutely relished the Romanticism of the movie Buffy the Vampire Slayer but the series starring Sarah Michelle Gellar was really where the parallel with infectious disease was most apparent. Not only did Buffy and her clan have to battle myriad monsters (i.e., different pathogens), they consulted librarian Giles to research what they were up against (i.e., made diagnoses). Different countermeasures were directed at different creatures, just like in infectious disease.

There’s another really poignant scene I’ve been thinking about from that series that concretizes an important point about infectious disease control. When infectious disease control systems are working, they’re invisible. Unbeknownst to the individuals being protected, it is keeping people safe. The “it” here are the epidemiologists, the public health department personnel, the microbiologists, and the infectious disease physicians. To paraphrase Men in Black: they go to places you need not go, see things you need not see.  Rarely do they get thanks — infectious disease is one of the least financially lucrative areas of medicine.

This invisibility can also work against them as people are unaware of what is keeping the demons at bay, beating the devil back; the victories are largely invisible to the people they protect. When the outbreak doesn't happen, nobody cheers. When the pandemic doesn't spread past its index case because someone in a state health department noticed a cluster and made the right calls in the first seventy-two hours, nobody hands out awards. When vaccination programs keep measles from circulating in a school, the kids who didn't get encephalitis don't know they didn't get encephalitis. The Ghostbusters don't get a parade after defeating Gozer. They get their funding cut and their lab shut down by an EPA regulator.

Similarly, public health agencies are subject to neglect and cuts in funding, vaccines are devalued and smeared, infectious disease expertise is attacked. We see the results plainly with measles re-establishing endemicity, Ebola outbreaks festering for over a month unnoticed, and minimal situational awareness of avian influenza.

Buffy has spent three years defending Sunnydale High from a parade of horrors — demons, zombies, hyena-possessed students, a principal who turned out to be a robot, and vampires. Nobody talks about it. Nobody acknowledges it. The monsters are fought mostly in the dark, largely alone, and when it's over, the next day proceeds as though none of it happened. The ordinary life of ordinary people continues precisely because someone was doing extraordinary work they couldn't see.

Then, at the prom, a student named Jonathan takes the microphone and reads from a card:

"We're not good friends. Most of us never found the time to get to know you. But that doesn't mean we haven't noticed you. We don't talk about it much, but it's no secret that Sunnydale High isn't really like other high schools. A lot of weird stuff happens here. But whenever there was a problem, or something creepy happened, you seemed to show up and stop it. Most of the people here have been saved by you, or helped by you, at one time or another. We're proud to say that the Class of '99 has the lowest mortality rate of any graduating class in Sunnydale history."

Buffy is named “class protector”.

That’s the closest most people ever get to understanding what public health actually does — not a press briefing, not a policy paper, but a kid at a microphone trying to put words to something he can’t quite name.

That's how infectious disease preparedness and public health work.

The people who keep pathogens from killing you are working with the same energy whether you're paying attention or not.

Prior to this scene Buffy states that she just wants her classmates to have a normal prom, no matter how many people she has to kill.

That’s what the entire infectious disease apparatus is doing as well — trying to give everyone a normal life where they can pursue their values and achieve, free from the dread and disruption of infectious disease.

That is the mission of infectious disease control.

Not to dominate people’s lives. Not to control society. Not to make itself visible.

The goal is to make normal life possible.

But civilization is full of unseen guardians.

Some carry stakes. Some carry microscopes.

Class protector — civilization protector —infectious disease physician