Death is not a relationship many people in wealthy societies have to deal with. Often set aside for rare events, death is unfortunately unavoidable. Therefore events as we experience today with COVID-19 stand-out for multiple reasons but in particular because we have to face a danger we cannot see and control.

Back in 2015 Bill Gates warned us that the world was not equipped for an epidemic outbreak. His experience with the Ebola virus convinced him that increase in R&D with a stronger collaboration between medical and military logistics and resilient health systems were crucial for overcoming such challenges. Experts as the former chair of the Global Health Council have also expressed similar views. 

Epidemics and pandemics have a long history, predating our digital age and affecting the global community at least once every generation. As it is an evil that cannot be seen or heard a dominant belief for millennia’s was that “polluted air” (miasma) associated with divine punishment was the cause of such ills. Accounts of miasma are so archaic that they be traced to plays as Sophocles’ Oedipus Rex or in medical records of ancient Rome (Galen plague). We would have to wait until the late 19th century for scientists as Louis Pasteur and Robert Koch to challenged and eventually overcome such common belief. 

Today more is known about infectious diseases and technological progress has been remarkable. The COVID-19 genome and mutations can be sequenced, downloaded and made available for diagnostic assays within seconds across the planet. Artificial intelligence although still in its early phases is assisting epidemics predictions by monitoring keywords out of social media, global news and health reports. AI also has an increasing role in diagnostics and drug candidates via design algorithms. Adjunctly to that CRISPR/Cas9 technology is being used by biotech companies to find solutions via molecular dynamics (Moderna, CureVac). 

Administratively the global community is also better prepared (The International Health Regulations) than in 2002 when SARS appeared. Nevertheless beyond this advancement we are still waiting for vaccines to enter the market, a process that violates our natural acceptance for instant gratification.

Epidemics as to no one surprise can be devastating. Most people have in mind the bubonic plague of the 14th century killing ⅓ of Europe’s population or the Spanish flu but a less known pandemic affected the Roman Empire when it was at its height during the reign of Marcus Aurelius.

At that time the Empire 60-75 m people lived within territories from Britain to the Middle-East (20% of world population) with Rome hosting over 1m inhabitants. The pandemic was likely caused by smallpox and claimed to have reached up 2000 deaths a day at its peak. Estimates of the death toll are difficult due to the epoch but are close to 5 million (Impacts of demographic catastrophes). 

Today the EU has a less impressive border but over 440m people living under territory and has 16 cities over 1 millions habitants. Movement of people is also in record numbers, close to 10 billion people take the railway each year and over 400m take the sea (eurostat). Airport passenger transportation has also significantly increased under the past decade from 4 Trillion of passenger-kilometers performed in 2005 to over 8 Trillion in 2018 (ICAO) surpassing 1 billion passengers for the first time in 2017 in the EU.

The Roman empire didn’t have the same flux nor density of population. Rough estimates put Early Imperial Italy with a population density between 20-40 per sq. km (Peasants and Slaves: The Rural Population of Roman Italy) while the average population density in the EU is 117 per sq. km (eurostat). These non-negligible parameters affect both speed and spread of pandemics.

Not all pandemics are alike, Africa and India are known for cholera outbreaks and China is associated with RNA viruses (influenza, SARS). At the differences from Cholera and Ebola these RNA viruses are transmitted airborne and were the source of 3 out of 5 most deadly pandemics of the 20th Century (1910, 1956, 1968). This is relevant to Europeans as the traffic between the EU and China has doubled to 10 million passengers in 10 years (2008-2017) with an annual growth rate of 6.7% (European Commission). 

Thanks to improvement in economic conditions Asia is projected to rise to 5.3 billion inhabitants by 2050 with predictions of strong air passenger growth in the Asia-Pacific region. More than half of the total number of new passengers over the next 20 years coming from these markets. China is planned to displace the United States as the world’s largest aviation market in the mid-2020s adding a billion new passengers by 2040 with India taking 3rd place (IATA).

The EU – China relationship is not the only factor to have strengthened, China’s outward travel has more than doubled in the past decade with an urban population 3x more dense (Can we contain the COVID-19 outbreak with the same measures as for SARS?). Outward travel will only increase with programs as the Belt and Road Initiative announced by Xi Jinping in 2013. A gargantuan initiative with close to 70 countries involved and the ambition to deepen trade routes between Asia, Africa and Europe. If completed it would accounting for about 65% of the world’s population and 1/3 of the world’s GDP (!). 

As the western world is opening up to Asia there will not only be free movement of goods and services but diseases. If developing countries do not improve their facilities in relation to their high and dense population growths the epidemiological transition may fail and lead to increase risks in epidemics. (The Impact of Population Growth on the Epidemiology and Evolution of Infectious Diseases). 

As Asia is catching up living standards in the West “wet markets” are often pointed to as the source of diseases (Epidemiologic Clues to SARS Origin in China). Described as farm markets on steroids they are considered problematic for two primary reasons 1) the number and variety of animals 2) poor animals condition of captivity inducing high stress. This cocktail is believed to create an environment where viruses from different species can mingle as attested by Dr. Kevin Olival (EcoHealth Alliance) and Michael Osterholm (Center for Infectious Disease Research and Policy). 

The international community and Chinese government have known the dangers of wet markets at least since 2003 when they enforced permanent shutdowns and concluded that such measures are not effective (The modernization of fresh food retailing in China: The role of consumers) as it leads to black markets or an increase of the spread of the virus (Closure of live bird markets leads to the spread of H7N9 influenza in China) .

While dealing with such outbreaks ancient Rome didn’t live in an era of such a degree of movement of people and services. And the plague that killed Marcus-Aurelius co-emperor Lucius Verus disappeared after 15 years. While we struggle with weekly confinements the Galen plague is a lesson of the dangers pandemics have as life in the Empire was never the same. Military conscription became problematic, the economy weakened and the coffers of the State depleted. Rome never recovered fully from it (Great Plagues of the Past and Remaining Questions) and is therefore argued by historians to be a major cause the crises of the 3rd century an epoch marked by instability and decline.  

Brussels is not Rome but as the EU opens up to the world and therefore Asia, the union faces not only economical but epidemiological challenges. The difficulty will be (as it did with Rome) to not fall into a dynamics of instability in an already increasing polarized society. Rome following the crisis of the 3rd century collapsed into smaller states and the EU faces tensions following Brexit. With an increase of global mobility and inclusion of developing countries, pandemics as Bill Gates warned us might define a generation.