Co-author: Charles W. Stiles, Captain, Medical Service Corps, United States Navy
It’s been almost 100 years since the 1918 “Great Influenza” ravaged the world and killed, by some accounts, up to 100 million people worldwide. The bottom line is that after 100 years of significant scientific research and medical progress, the United States is poorly prepared to fight a deadly novel-strain of influenza, which can emerge at any time. Unlike seasonal influenza, humankind has no immunity against a novel-strain and your “flu shot” only gives you limited protection to known viruses. The authors offer a worst-case fictional scenario that endeavors the reader to imagine how a pandemic similar to the Great Influenza would disrupt and forever change the current world order.
The Director of National Intelligence in 2015 clearly expressed the effect of such a pandemic. “If a highly pathogenic avian influenza virus, like H7N9, were to become easily transmissible among humans, the outcome could be far more disruptive than the great influenza pandemic of 1918,” James Clapper told a Senate committee. “It could lead to global economic losses, the unseating of governments, and disturbance of geopolitical alliances.” Such an outcome would have clear homeland and national security concerns to the United States.
The following is a fictional account of the emergence of a highly contagious influenza (HCI) pandemic and its effects on the world and the United States. It’s just a matter of time when the next novel HCI strain emerges. If that strain emerges to have a high infectivity and mortality rate, then there will be unprecedented impacts to populations, critical infrastructure, and global governance unlike what has been experienced by anyone alive today. We are overdue for such a pandemic and ill-prepared to face it 100 years later.
This Spring or Fall
A HCI virus strain emerges suddenly on a rural poultry farm west of an Asian city. Numerous cages of infected chickens shipped from that farm arrive at several legal and illegal live markets within the dense urban districts of the city. A child wanders about the market climbing and peering into cages as his mother barters for a chicken to boil that evening. The merchant butchers the chicken and sells it to the woman, who leaves with her son. This process repeats itself numerous times. The merchant’s direct contact with live and butchered birds results in his infection and within days he starts to show symptoms.
His symptoms worsen, but he continues to work in the market selling his infected birds so he can provide for his family. The air in the market is stagnant as chickens and ducks move about their cages, kicking up contaminated dust and flapping their wings. The merchant is ignoring his growing aches and cough, thinking that the dust, cool mornings, and cigarette smoking are causing his asthma to flare up. The merchant is also exposing his immediate family to the virus through his deep coughs in their small, poorly ventilated apartment. His elderly mother, pregnant wife, and young son soon shows signs of illness. Within several days, he is unable to work due to a headache, high fever, and labored breathing. Cyanosis, or the compromised ability of the lungs to exchange oxygen, sets in and the merchant’s lips and fingertips turn a blue hue as respiratory distress increases. The merchant’s brother rushes him to the hospital where he is admitted but misdiagnosed as having a routine, but advanced, case of seasonal influenza.
A ventilator does little to help the merchant’s growing distress. After several days of hospital care, a secondary bacterial infection overtakes his lungs with surprising speed. Numerous doctors, nurses, and facility staff have come in direct contact with him or his waste. Other patients with similar symptoms begin appearing at different hospitals across the city and the virus shows an alarming airborne infectivity rate. The virus is beginning to gain a foothold in the city.
The virus is now showing a high morbidity rate as more cases appear in clinics and hospitals. Some medical staff see the very early stages of a serious influenza epidemic with pandemic possibilities. The influenza does not respond to the typical medical regimes and treatment. The elderly and young children are becoming very ill, very quickly. What medical staff initially believed to be seasonal influenza is now coming into focus as something quite different and lethal. Deaths are now occurring at an alarming rate and the merchant passes away quickly, followed by his mother, who was already in poor health.
The city’s health board realizes it has a significant problem and notifies higher-level government officials, who quickly descend upon the health board and demand that there be no public announcements. The government’s leadership is concerned about the negative societal and economic effects that would occur if the city were labeled the epicenter of an epidemic with pandemic possibilities; they hush and chase away reporters from the city’s main newspaper. Despite pleas from various hospitals, no public health warnings about a novel HCI virus strain with an alarmingly high mortality rate go out for another week. This delay dooms thousands of citizens as the virulent strain spreads and deaths begin to skyrocket in the city.
The World Health Organization (WHO) is able to insert a team into the city to collect case-rate data and laboratory specimens. The team utilizes standard protocols and determines that a novel HCI is raging unchecked. Reports of cases outside the city come in along trade and travel routes. The WHO issues orders to government authorities to cull entire bird flocks inside and outside the city, to shut down plane and train travel, and to deploy immediate public healthcare precautions. Farmers and merchants refuse to comply and protest after seeing the threat to their livelihood.
Reports of cases are now appearing in many countries, mainly in cities within Europe and the United States that handle Asian international flights, such as San Francisco, Los Angeles, and Washington, D.C. The WHO issues a global pandemic warning. Within weeks and months, the HCI pandemic sweeps across the U.S. in its opening first-wave salvo. Epidemiologists are shocked by the uncharacteristic virulence of the first wave. The public healthcare system is quickly overwhelmed, with many of the medical providers succumbing quickly. Many patients infected with the HCI seek out hospitals but are turned away because of a lack of available beds and supplies. Sadly, the “walking well” – those who fear they are infected but are not – show up at healthcare facilities and expose themselves to the virus and many become infected. Healthcare worker absenteeism jumps significantly due to death, sickness, fear, caring for family members, or grief of loss. Nurses and medical equipment, especially ventilators, face masks, and rubber gloves, are all in short supply. Antiviral medications and antibiotics are also in short supply and the mortality rate from secondary bacterial lung infections is growing.
Mortuary and burial services are overwhelmed and refrigeration trucks can’t contain the growing number of bodies spilling out of hospitals. Some funeral homes and crematoriums simply refuse to take bodies that have died from the influenza. Casket manufacturers cannot meet demand and many people resort to burying loved ones in simple wooden coffins while others are only wrapped in sheets and plastic tarps. Numerous bodies are going unclaimed, resulting in hasty burials in shallow graves or trenches dug for mass graves.
Like healthcare workers, absenteeism of those that run much of the critical infrastructure increases and leads to the loss of basic services. Trash removal, postal delivery, police, fire, and ambulance services all become spotty, especially in cities. Instances of contaminated water have increased along with the corresponding orders to boil water. The shelves at grocery stores are bare of certain essentials due to a breakdown of production, delivery, maintenance, and reliable electrical power for refrigerators and freezers. Fuel for backup generators is sparse.
State and federal authorities are stepping in and canceling all large gatherings of people, to include cinemas, sporting events, concerts, and even protests against the government. Shopping malls and outlet stores are empty of customers. The retail industry is suffering economically as people fear venturing out and becoming infected. All forms of travel are depressed and some are even restricted. Each community is experiencing the pandemic as a local event and many communities focus inward and protect their own citizens.
The United States suffers a huge economic downturn and falls into a major recession like that seen in the 1930s. The failing economy only compounds problems. Trust in the government wanes. Opportunists take advantage of the overwhelmed federal and state governments and some protests in major cities turn into riots. Due to absent emergency responders, anarchists and arsonists destroy and burn huge swaths of city blocks across the country.
The first wave of the HCI pandemic passes and the United States joins the world as it tries to come to terms with what it is facing; however, the worst is yet to come. At the federal level, the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention are overwhelmed with requests for help and support. After much delay, the HHS secretary asks the president to use Department of Defense (DoD) assets to assist domestically.
Requests come into the State Department from other countries seeking assistance, because many of their governments are no longer able to function. Violent coups overthrow several less-stable countries in South America, Eastern Europe, and the Middle East. A tectonic shift in global governance is now a forgone conclusion from the high mortality rate in those countries with limited public health infrastructures and access to antiviral medicines and vaccines.
Virologists diligently work on a vaccine but realize that a national-level vaccination response and a person’s ability to build immunity to the virus will not occur until past the peak of the second wave that soon hits the United States. The virus mutates further as it adapts to its human hosts and the second wave is dramatically more severe in terms of mortality than the first wave.
As the second wave approaches its peak, the loss of many people in the critical infrastructure sectors – energy, water and wastewater systems, transportation, and communications and information technology – becomes dire and is felt most greatly in cities. Electricity brownouts and blackouts occur, raw sewage spills contaminate potable water sources, trash removal services have ceased, and logistical shipments of foodstuffs, medical supplies, and fuel have dropped 50 percent. Grocery stores run completely empty from demand or looting. Those willing to risk exposure – or who are already sick – take to the streets in search of food, water, and fuel.
Dead bodies are seen in empty city lots or along sidewalks, going uncollected out of fear. Widespread arsons, looting, and vigilantism result in many cities, such as Atlanta, Chicago, Detroit, Los Angeles, New York City, and Philadelphia, prompting declaration of martial law. Hollowed-out police, National Guard, and active-duty ranks cannot enforce peace or provide aid effectively.
An unprecedented mortality rate, nearing 45 percent, consumes the country of India due to its dense population, cultural norms, and poor infrastructure. India misinterprets Pakistan’s overtures on its disputed border and it pushes the two nuclear-armed states to the brink of war. Iran mistakes a commercial airliner as a military threat and shoots it down in international airspace. People from Central America and Mexico pour over the U.S. Southwest border in record numbers – from 500 a day to over 4,000 a day – to search for medical supplies and the false hope that the U.S. can save their families. A similar mass migration occurs across Europe. The United Kingdom and Australia have closed their borders.
Opportunist nations are emboldened and U.S. national security interests in the Strait of Hormuz, Israel, Taiwan, and South Korea are threatened and exploited. A U.S. missile cruiser is attacked in the South China Sea and desperate civilians overrun several overseas bases in Japan, Guam, and Germany seeking help. Passage through the Panama and Suez canals stops. A large oil supply pipeline ruptures from sabotage and lack of maintenance. Russian hackers attack various financial institutions and the energy grid within the U.S. to sow instability and anger within the U.S. population. The global chaos and prophetic beliefs of radicalized terrorists push many to pursue martyrdom through suicide bombings of soft targets, adding to the world’s misery.
Rumors and conspiracy theorists abound on global social media and many people ignorantly blame the U.S. for designing this deadly virus to kill non-Americans. Other conspiracies spread that the U.S. will not share air or vaccines once developed. U.S. embassies in half a dozen Middle East, African, and European countries are overrun and burned, with many staff dead or missing.
Key pharmaceutical producers around the world mass produce an identified vaccine. The administration of the vaccines within the U.S. is by a lottery system based on age groups, those most at risk, and occupation. Members of the executive, legislative, and judicial branches, and their families, are given early vaccinations, angering many.
The second wave is touching every life, whether rich or poor, rural or urban, educated or not. In defiance of their own isolation recommendations, both Houses of Congress sit in a televised joint session, with most wearing facemasks and wristbands indicating they are vaccinated. Only half of the cavernous chamber is full and most are spread out. Partisan tempers flare, blaming the president and her administration for not doing enough to prepare for this global and national catastrophe. Half of the elderly Supreme Court justices die or are too sick to attend. Three of the Joint Chiefs sit sternly, listening intently on the debates.
The president has not been seen in several days and there is wild speculation that she is gravely ill or has died. A handful of news commentators openly express concern about a military coup, while others uncomfortably dismiss such notions. The U.S. now focuses its full efforts inward in a desperate fight to ensure the continuance of a constitutional form of government and its relevance in a post-pandemic world.
The full effects of the third and final wave of the HCI pandemic passes its peak and varying estimates of the global mortality rate are an astounding 25 to 35 percent. The emergence of a new world is undefined and the United States’ position in that world is unclear.
 Taubenberger, J. K., & Morens, D. M. (2006). 1918 Influenza: the Mother of All Pandemics. Emerging Infectious Diseases, 12(1), 15-22. https//dx.doi.org/10.3201/eit1201.﻿050979
 Clapper, J. (2015). Statement for the Record, Worldwide Threat Assessment of the US Intelligence Community, Senate Armed Services Committee.
Charles W. Stiles, Captain, United States Navy has over 30 years’ experience as a Navy Medical Department Officer, where he has served in numerous assignments. He is a recent graduate of the National Intelligence University. His interest in HCI pandemics is driven by his study of the nexus between U.S. Northern Command and its maritime component U.S. Naval Forces North in responding to global infectious disease in order to protect the homeland, provide global relief, and its effect on the U.S. Intelligence Community.
The authors are responsible for the content of this article. The views expressed do not reflect the official policy or position of the National Intelligence University, the Department of Defense, the U.S. Intelligence Community, or the U.S. government.