The Soviet Union, for instance, ran a top-secret bioweapons program for decades. Tens of thousands of researchers sought to enhance many different pathogens. They even developed a weaponized strain of the smallpox virus, accepting the likelihood that use in war would also impact the Soviet population. 

A subsequent smallpox outbreak in Aralsk in 1971 triggered an emergency lockdown and vaccination campaign, and was only later linked to an aerosolized smallpox test on an island in the Aral Sea. The Soviets signed the Biological Weapons Convention the following year, but maintained its bioweapons program nevertheless. The smallpox outbreak was concealed for decades. Defectors alleged that the same program sought to engineer bacteria such as plague to resist antibiotics. 

Last week, Russia reportedly quarantined hospitals, dispatched FSB security agents, and deployed personnel in protective suits following the death of a single researcher studying plague at a weapons-lineage Irkutsk laboratory. Given the lab’s protocols and DNA sequencing capabilities available, I would expect Russian authorities to have identified the responsible pathogen, but they have yet to publicly share any relevant information. 

Since Russian plague researchers are routinely vaccinated and would normally be treated with antibiotics following an accident, a researcher dying from natural plague would be extremely unusual. The authorities’ stringent quarantine response, which has continued after they claimed the death was due to a “pneumonia of unknown etiology” rather than natural plague, implies they believe there is a substantial risk of an outbreak of something else.  

This means we are dealing with either inaccurate reporting, major safety failures, an engineered vaccine-evading and pan-resistant plague strain, or a different pathogen entirely. In other words, there is a nontrivial chance that the responsible pathogen might be an engineered biological agent more transmissible than the moderately contagious pneumonic plague. 

What does this mean for the rest of us? Could Western defenses withstand an engineered pandemic agent? Judging from recent meetings of the National Academies, much of the medical and political establishment appears to believe that better vaccines and therapeutics can protect us from engineered pandemics. Unfortunately, defenses that typically work against blind evolution will fail miserably against a competent attacker who can see and design around them. 

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By Filippa Lentzos

I specialize in biotechnology and ecological engineering: the creation of genes and organisms that can persist or even spread on their own in the wild. I’m keenly aware of the dangers of uncontrolled exponential growth. For this reason, when I invented CRISPR-based gene drive, a way for a single researcher to engineer entire wild populations, I withheld the technology until I could be confident that it favored defense: gene drive is slow, conspicuous, and capable of countering itself. Pandemics need not be slow or conspicuous: they can spread fast like SARS-CoV-2, or stealthily like HIV. A good guy with a pandemic cannot counter a bad guy with a pandemic. 

Imagine that Covid-19 had killed 80% of those infected. Nations would have collapsed long before we had enough vaccines. While many countries now aim to approve new vaccines within 100 days of spotting a novel disease, and the United States hopes to manufacture enough doses for every resident within 130 days, that won’t be enough. To understand why biomedicine will reliably fail against deliberate pandemics, consider a game of darts.

Picture a pub with a back wall covered in dartboards. Imagine that damage to any board corresponds to human casualties, and there are many boards — one for every type of pathogen capable of spreading efficiently in humans. The player represents evolution by natural selection: blind, amoral, and possessed of near-infinite darts — pathogens — but primarily limited to repeating strikes on or near targets it has already hit. 

Covid-19, regardless of its origin, was caused by a stray dart unexpectedly striking a new region of the coronavirus board. Evolution followed by tossing a flurry of darts nearby: first at the same location, representing the ancestral virus spreading across the world, then expanding outwards incrementally with variants — Alpha, Beta, Delta, Omicron, and so on. As infections accumulated, acquired immunity built up padding around points of impact, reducing the damage from subsequent darts that landed nearby. The Covid vaccines added padding, but had to be constantly updated as the variants moved further away. 

Our vaccine strategy only works because evolution is blind. It generates enormous numbers of constantly mutating darts, but it has no idea how far away it needs to launch them to avoid the padding. This is why vaccination can keep pace against natural threats. Even a rapidly mutating virus — a series of darts moving steadily away from the initial strike — takes months or years to approach the edge of the padding. 

But an intelligent player, sighted, will immediately throw darts outside the padded regions. In our metaphor, a dart’s mutations determine whether it is functional enough to strike the board, and whether it is sufficiently different from earlier darts to land outside of any padding. The most important reason we haven’t yet seen any deliberate pandemics is the lack of known, functional, accessible darts. Even some historically successful darts like the 1918 influenza virus, called the “mother of all pandemics”, would be unlikely to spread today due to population immunity triggered by modern descendant strains. Still, we should not mistake “isn’t widely known” for “doesn’t exist.” And AI is learning. 

Earlier this year, a lab seeking new ways to eliminate antibiotic-resistant bacteria trained an AI model on thousands of genomes of harmless bacteria-infecting viruses called phages, carefully excluding all human-infecting viruses. Sixteen of 300 AI-redesigned darts struck the target: they could infect and kill bacteria. Imagine if the experiment were repeated using a future model trained on human-infecting viruses. Even if almost every design were to fail, it’s easier for a skilled researcher to make a “library” of a thousand distinct pathogen variants in parallel than to make 10 individual variants. 

The core lesson of evolutionary engineering is that there’s no need to know which design will work. Make them all, and let evolution sort it out. Worse, some well-intentioned researchers have built and shared preliminary AI models intended to predict which combinations of mutations in an existing dart would hit the board in an unprotected region; their results have been published in the most prestigious journals. In a world where nature is the only enemy, that’s a great plan: we could improve vaccine designs to absorb more of nature’s subsequent strikes. But it’s a terrible idea if anyone is malicious. While current models probably aren’t accurate enough, sufficiently improved versions would allow a single skilled individual to generate libraries of immune-escaping variants of many human viruses — including those that have been safely controlled by vaccines for decades. 

We might prefer to believe that we live in a world where no one would do such a thing. The evidence suggests otherwise. A key question is whether there is a limited number of possible immune-escaping variants. The answer appears to be no: biological sequence space is unimaginably vast, and experiments have demonstrated that very different sequences can encode the same function. That means there are extraordinarily many different ways to redesign the surface of a pathogen so that it can escape immunity and still cause a pandemic by hitting the board in an undefended location. Most are never explored by evolution, which relies on small mutations, and therefore tends to proceed in steps rather than via huge leaps.

Now combine near-limitless variants with evolutionary engineering. A skilled attacker with a sufficiently predictive AI model — better than any that exists today, but likely to be trained within a few years — could synthesize and throw immune-evasive functional darts faster than we could possibly add padding with vaccines. A reactive vaccine strategy is nearly useless against anyone capable of continually releasing new pandemics. 

But escaping immunity is only part of the danger, for not all darts are created equal. Evolution optimizes for replication rather than harm, yet even it occasionally throws something devastating by accident. The myxoma virus killed over 90% of initially infected rabbits and crashed their populations across multiple continents. Still, it was not designed to cause as much harm as possible.

An intelligent enemy intent on destruction would make the darts explosive. Suppose one were to take a hollow dart and fill it with an explosive that detonates upon impact. If it strikes, the explosion will cause far more damage than any natural dart.  

In my professional judgment, there are many potential explosives available. No such explosive is publicly known to work with any particular dart, and establishing which combinations are effective would pose a grave security risk: once scientists identified a compatible pairing, the resulting weapon would become just as accessible to skilled individuals as the dart alone. 

We can try to prevent misuse by controlling access to anything that could plausibly be turned into a functioning dart, including relatively harmless respiratory pathogens that could be re-surfaced by AI. This wouldn’t stop Russia, but it could seriously impede extremists. Yet most gene synthesis firms, which manufacture bespoke DNA molecules for their customers, do not employ effective screening. My laboratory recently showed that it is possible to legally purchase all of the DNA pieces required to recreate the 1918 pandemic influenza virus, even though it is a “select agent” supposedly under lock and key. Such pieces can now be assembled by anyone with common laboratory skills. 

Software tools capable of detecting attempts to acquire the relevant DNA are freely available, but their use is not legally required in any nation. While some laws have been drafted, they don’t specify that screening must be able to detect AI-assisted acquisition using modern DNA assembly techniques. Until that changes, we won’t be able to control access to the biological materials — the hollow darts and explosives — necessary to create pandemic weapons. 

Absent physical controls, our primary defense is ignorance: we lack publicly credible examples of hollow pandemic-capable darts, let alone explosives to fill them. But I doubt that we scientists will be able to restrain ourselves from investigating alleged hollow darts and explosives and openly publishing our findings. Most of us still assume that all knowledge is worth having and best shared freely. 

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The moment someone publicly identifies a compatible dart and explosive, all those thousands of people with the relevant laboratory skills would likely be able to build a pandemic weapon. Add an AI capable of generating immune-escaping functional variants, and an attacker could produce an arsenal of explosive darts. Even if vaccines could somehow both withstand the detonation and be made much faster than they are today, we would have to keep designing, manufacturing, and distributing new ones as the attacker changed the target area. 

I am deeply alarmed by this trajectory. But I’m also exceedingly biased. I specialize in playing nature’s replication game in unorthodox ways. I’ve evolved molecular tools by harnessing viruses that infect bacteria, invented methods of editing animal populations, and performed the early research into the invasive potential of mirror-image bacteria. I’ve also worked in security, building and testing DNA-synthesis screening systems and “red-teaming” AI models to see how readily they can be used to cause harm. To me, competently designed weapons appear considerably more obvious and easier to build than they actually are. 

But difficulty and obscurity are not reliable defenses. Good security practice assumes that the adversary is more cunning than you, possesses capabilities you have never imagined, and knows of every defense you’ve prepared. They can choose when and where to strike. Given a sufficiently powerful weapon, they need only succeed once. And AI is democratizing competence. 

None of which guarantees catastrophe. What I see as obvious and imminent could take many years, and very few people want to cause widespread destruction. But even a small annual probability adds up. We must prepare, then, for someone to accidentally or deliberately release a competently designed pandemic weapon. If that day comes, it would be profoundly unwise to rely on biomedicine alone.

As a life scientist, it’s painful to admit that my field cannot solve the problem of deliberate pandemics. We can’t rely on developing and distributing a new vaccine or treatment after each attack. Instead, we should avoid becoming infected in the first place. 

Stockpiled protective equipment can filter out viruses and bacteria before they’re inhaled; and they can be killed mid-air by far-UV light (radiation that kills pathogens without harming human tissue) and glycol vapors (a gaseous, odorless component of stage fog). These technologies can suppress airborne pathogens without first needing to recognize them. But they’re neglected by a biomedical establishment intent on fighting the last war. 

The solution is to install germicidal defenses in buildings to fight every kind of respiratory disease. Evolution throws millions of darts each day, causing widespread misery, lost economic productivity, and thousands of deaths. We don’t need to sit here and take it. The more spaces equipped with germicidal defenses to block routine infections and seasonal flu, the fewer our sick days and the lower our medical bills. If recent history and the developing situation in Irkutsk are insufficient to spur action, the ongoing toll of infections and resulting chronic diseases should be reason enough to act. 

Safeguarding civilization begins with fighting the common cold. Let’s screen off the dartboards with germicidal curtains as fast as we can — before an intelligent enemy throws an explosive dart.

They didn’t diagnose it in A&E though. That happened in the follow-up appointment. I often dwell on that afternoon, in the run-down wing of a hospital in Haywards Heath, replaying the transition from the innocence of the drab waiting room to the gut-punch that was delivered behind the doctor’s door: “Mr. Burley, you have Parkinson’s disease.” My life divides now between before and after Haywards Heath.

My first instinct was to keep it secret, and I did — for a year. Many with Parkinson’s do the same. The urge to hide it is widespread among those who have it. Almost 23% report concealing their diagnosis from family; 85% report feeling embarrassed by their condition, and 57% avoid or cancel social situations. Sufferers are scared — rightly or wrongly — of being written off, patronised or defined by the illness. Even more deeply: the less visible it is, the further away seems the endgame. Parkinson’s is a progressive, degenerative disease. It will get worse.

So you can’t hide it for long. It doesn’t help that the medication often has side effects as wild as the symptoms themselves: daytime sleeping, involuntary muscle movements, impulse control disorders and vivid hallucinations. Any of this will grass you up pretty quickly. Realizing this, I began to be open about it. But as far as I was aware, it was still invisible to the outside world. Over the years, I have done plenty of public events and on-camera appearances, and nobody has said a word about the way I move or hold myself steady. It’s only now I realize how important this has been: it feels OK for people to know I have Parkinson’s, provided they can’t see it.

I didn’t feel like a victim, never saw myself as disabled, nor felt any embarrassment because I looked “normal”. Until last week, that is, when, for the first time, I felt the sting of the pointed finger and accompanying laughter directed at someone weird, different, or disabled.

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Camilla Tominey’s Sunday morning political show on GB News starts mercifully late, but for the insomniac wing of the Parkinson’s massive, you’re always running on empty. I’d managed only three hours the night before. The heat didn’t help, but interrupted or occasionally non-existent sleep has been a permanent feature of my life, whatever the weather, since the diagnosis. I have learned to live with it.

Given my insomnia and unpredictable symptoms, why had I agreed to a live TV appearance? This is a side of Parkinson’s that you don’t hear about very often. For me, particularly over the last year or so, the corrupted file on my internal hard drive has rewired me. I am more driven, more creative, and more willing to take risks.

This isn’t unusual: 20% of those with PD report a surge in creativity and the drive to achieve more. There are countless stories of people who, without any prior interest in the arts, discover a new, often intense, obsession with poetry or opera, sculpture or pottery. These effects are created by a powerful combination of the psychology of time being short, the condition itself, and medication, which can be “disinhibiting”.

So, there I was, shattered but confident in the studio next to Camilla, looking forward to countering the increasingly hysterical press coverage of the small boats “crisis”. My Parkinson’s didn’t cross my mind; I was focused on providing some engaging and challenging content. I love the energy of live TV and before I knew it, it was all over, and all was well.

On the train home, I opened X, expecting some pushback. Obviously, many GB News viewers would disagree with my plea for some perspective on migrants. So it was no surprise to read that they thought I was “obnoxious”, “awful”, and “dreadful” — in a way, that’s what I was there for.

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However, a new theme started to emerge among the messages, complaining that I couldn’t “keep still”, and thought I was “hard to watch”, and “very odd”. One concluded I must be “pissed/hungover/on something”. Another asked, “Who is this pisshead on GB News?” “Is he on drugs?” Yes, I was, one decided “(He’s) clearly coming down from a kilo of Charlie.”

I was confused. Had I been slurring my words or swaying in my seat like a drunk? Or was it simply that I was irritatingly deviating from Reform UK’s talking points? I needed to check. So, I took the painful step of rewatching the newspaper review. The truth was sobering: true, there was some gross exaggeration by a certain unpleasant cohort; but they had a point. There was a hesitation in my voice, and I did sway in my seat. It was briefly upsetting to be so cruelly sent up, but I appreciated the brutal economy of one two-word takedown: “Twitchy Twat.” Take a bow, whoever wrote that, and while you are at it, rot in hell.

So it wasn’t the piss-taking that bothered me, so much as the stark realization that, after that appearance, I’m no longer an invisible Parkinson’s patient. My TV appearance marked an unwelcome milestone on the road to a frightening future.

A long time ago, at the beginning of what you might call my Parkinson’s journey (Destination: the grave), I arrived at my first PD exercise class determined to break the habits of a lifetime, become a good joiner, and embrace my group of fellow sufferers. My resolve deserted me the moment I put my head around the door and saw how these people moved, how ill they seemed, and how old they were. Afterwards, I couldn’t get out fast enough, and I’ve been running ever since. But I now know that one day I’ll have to stop running and take my place in the group.

Unless, that is, the elusive breakthrough comes and we work out how to slow or cure the disease. You never know; Parkinson’s is, above all else, an unpredictable fucker.

As the past year came to an end, the same stubborn arguments which have been spinning around the world’s hamster wheel for the last three years were aired again — this time about China’s decision to abandon Zero Covid, and what this might mean for the rest of the world in terms of variants, Covid spread and the health of the general population. We don’t want to rehearse these arguments again, but they are vital: they cut to the heart of what lessons global societies will take from the Covid-19 pandemic and associated policy response, and how institutions will balance health and disease in the future. It’s too easy to say that we should just move on, because the future health of human societies depends on what decisions now are taken.

It’s pretty clear that China abandoned Zero Covid because it didn’t work, was causing huge socioeconomic and psychological harm, and threatened to undermine the political control of Xi Jinping. The writing was on the wall when footage emerged in August of shoppers in a Shanghai Ikea stampeding for the exit after authorities sought to seal off the store and send everyone in it to quarantine following the discovery of one shopper who had been exposed to an asymptomatic six-year-old child. Once mass protests began to spread in November, the decision was taken to move on before they became a threat to the regime.

To us, a number of conclusions can be drawn, which we discuss in The Covid Consensus. Clearly, lockdowns could only work in a very limited way, to reduce spread for a short period of time; they were therefore impractical for any length of time without causing enormous harm, which is why Zero Covid was impossible. Moreover, in spite of China’s severe attempts to prevent travel, the spread of a highly infectious respiratory virus cannot be shut down completely in the era of global supply chains, even with hermetically sealed borders, as proved to be the case in Australia and New Zealand.

Nevertheless, many seem to be trying to draw different and nonsensical lessons, showing that nothing has been learned from the past three years. Once again, the Western media is stoking unnecessary fears with panic-stricken reports of “China’s new Covid nightmare”. The rapid infection of potentially more than a billion Chinese people, we are told, is likely to result in countless deaths among the population, and spark the emergence of dangerous new variants that could lead to “a global catastrophe”, as millions of potentially disease-carrying citizens prepare to celebrate the reopening of the country’s borders by travelling to all corners of the world.

So, instead of celebrating the end of the Zero Covid prison in which so many Chinese have been incarcerated, during the past week, several countries — including the US, Japan, Italy, Spain, France and, most recently, the UK — have reacted by reintroducing restrictions for passengers from China, requiring them to show a negative PCR or antigen test before boarding.

But are such fears justified? First, let us explore whether China is really heading for a public health disaster of apocalyptic proportions, as the news would have us believe. According to the Chinese government, the country is registering around 5,000 new cases, and only a handful of Covid deaths, per day. Official deaths since the start of the pandemic are just over 5,000. These numbers are universally considered to be hogwash; China has routinely been accused of downplaying infections and deaths for political reasons. The World Health Organization, for example, reports around 150,000 new cases, and 400 deaths, per week, and a total of just over 30,000 deaths.

As far as the latest wave is concerned, there is at least an official explanation for the discrepancy: China recently announced that it will include only deaths from pneumonia or respiratory failure in its official Covid-19 death toll; deaths that occur in patients with pre-existing illnesses, on the other hand, will not be counted as Covid-19 deaths. If true, this contrasts starkly with the very “liberal” approach to Covid-19 deaths (and hospitalisations) adopted by most Western countries throughout the pandemic, and still widely used, whereby any deceased person who has recently (or even not so recently) tested for Covid is classified as a “Covid death”, even if the death was manifestly unrelated to Covid. Figures related to new cases are even more unreliable, since they obviously depend on the number (and method) of tests that are carried out.

One thing, however, is certain: in the coming weeks and months, a huge portion of the Chinese population is going to catch the virus. The Institute for Health Metrics and Evaluation (IHME), for example, estimates that around 1 million Chinese people are already getting infected every day. Some reports claim that 250 million people across the country have been infected just in December. How many deaths this leads to depends on a number of factors, including the ability of the Chinese authorities to put measures in place to protect those who are actually at risk of developing a serious illness from Covid-19, namely the elderly and those with serious medical conditions. The IHME expects close to 300,000 Covid deaths by April 2023 — roughly 100,000 deaths per month (3,000 per day).

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These numbers may seem shocking, but they need to be contextualised. Assuming that a large percentage of the 1.4 billion-strong Chinese population eventually catches Covid, as seems likely, this would amount to a minuscule infection fatality rate (IFR) — less than 0.001%. Most of the deceased are also likely to be very elderly people who would have died within a short time — as was the case for the overwhelming majority of Covid-related deaths in Western countries. In fact, since more than 10 million people died in China in 2021 (the most recent year for which there are statistics), this figure — even if it continued at that rate throughout the year — would lead to around a 12% mortality increase, broadly in line with global averages elsewhere in 2020.

We also need to keep in mind that the dominant strain in China at the moment appears to be a subvariant of the Omicron variant BA.5 (BA.5.2.1.7), also called BF.7, which we know to be more transmissible but much less lethal than previous variants — exactly the kind of evolution you would expect to see in a virus like SARS-CoV-2. Indeed, Chinese authorities have confirmed that the virus causes relatively mild symptoms in the vast majority of those infected. There’s little reason to doubt this, as much as one may be sceptical of the information coming out of China.

And yet, Western politicians are now telling us that the reason we need new restrictions is that, as the Chair of the Defence Select Committee Tobias Ellwood said, “we simply cannot trust Chinese data”. Such claims would hold more water if that same Western establishment hadn’t spent the best part of the past three years taking the Chinese Covid-19 statistics at face value, and using them as evidence for the effectiveness of lockdowns. Up to March 2020, 39 of 42 reproduction number estimates were based on Chinese data, as was the Imperial College report that predicted 510,000 deaths in the UK, which would fall to somewhere between 5,700 and 39,000 with Chinese-style “suppression” measures. Needless to say, those predictions turned out to be wildly inaccurate.

In other words, the Chinese data was deemed perfectly reliable insofar as it was useful to justify restrictions in the West. Today, on the other hand, it is accused of being unreliable… in order to justify restrictions in the West. The doublethink is jarring — and the results are likely to be similarly flawed. Just as lockdowns failed to contain the spread of the virus within countries, previous attempts to prevent Delta and Omicron variants from spreading beyond India and southern Africa, respectively, also failed miserably. Even the WHO considers travel bans to be “usually not effective”, while Andrew Pollard, chairman of the UK Joint Committee on Vaccination and Immunisation, also admitted that “trying to ban a virus by adjusting what we do with travel has already been shown not to work very well”. Neither is there any evidence that pre-departure testing will “help slow the spread” of the virus, as claimed by the CDC’s director Rochelle Walensky. In July, for example, French researchers found the Omicron variant in wastewater from two commercial airplanes that flew from Ethiopia to France in December 2021 even though passengers had been required to take Covid tests before boarding, concluding that mandatory testing before boarding “did not prevent massive importation of Omicron variant into Europe”.

More importantly, why would we want to do that? Data from last month suggests a majority of people in Western countries have had coronavirus infections, and that prior infection, even in the unvaccinated, offers strong protection against BA.5 Omicron hospitalisation. Moreover, the Omicron subvariant that has been spreading in China has been detected in the US, Europe and rest of the world for many months, which means we also have good levels of natural immunity to that subvariant (as well as high vaccination rates, which were told were the golden bullet to end the pandemic). So, there’s no reason to fear coming into contact with a Chinese tourist any more than there is to come into contact with any other human being.

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Furthermore, not only is there “currently no evidence” to suggest that a new and dangerous strain of the virus has emerged in the Chinese population, but there’s no reason to believe this is likely to happen either — or at least it’s not more likely to happen in China than anywhere else. “The likelihood of variants emerging [in China] is the same as it is in other places where there are Covid waves,” said Pollard. Besides, as noted already, even if it were to emerge, it would spread across the world regardless of the measures put in place, just like all previous variants.

Why, then, are policymakers once again going down this route? Part of the explanation is that politicians, by peddling a pro-lockdown narrative for the past three years, have now created an artificial demand for restrictive measures among their fear-stricken constituents, some of whom are now even making the case for wearing masks forever or for the permanent institutionalisation of what Giorgio Agamben might call “bare life”. Even more worryingly, it appears to indicate that Western governments have little intention of giving up the powers they’ve claimed under the guise of “fighting the virus”. While these current travel restrictions won’t affect the daily lives of Western citizens, they nonetheless show how easily “lockdown laws”, many of which remain in place in the UK and other countries, can be reinstated. If restrictions can be arbitrarily brought back at any moment in the name of public health, what’s to stop governments from abusing these powers once again in the future? For instance, the British government’s “Living with Covid-19” guidance, published in February 2022, states that it “will retain contingency capabilities and will respond as necessary to further resurgences or worse variants of the virus”.

The threat of such “capabilities” relates to a more fundamental issue, which is how human societies relate to illness and disease. The pandemic threw this into the foreground, and offered two contrasting approaches. The first is the biomedical approach, which has been championed by Bill Gates in his book on the pandemic and subsequently by Joe Biden in his new pandemic policy, which relies on the rapid production of vaccines, while citizens will need to wait in lockdown until these new products are available.

The alternative requires us to move beyond the guidance — or tyranny, depending on your point of view — of “the science”, and to recognise the role that philosophy and humanistic knowledge has in human life. Whether or not humans choose to embrace this way of living is ultimately a question of values. We can either confront the truth that death is — and always will be — a fundamental part of life, embrace the case for living well and healthily while we are alive, and recognise the place that human contact, exchange, and the sharing of bodily and social space has in well-being and therefore in health. Or, we can assign more value to the technical shield which we have been constructing around ourselves for the past decades. Looking at what’s now playing out in China, we know which we prefer.

Black Britons and poor Britons have suffered the most. This could be a propensity of the Coronavirus, but it might simply be a function of the contemporary United Kingdom, where living in the richest areas of the country buys you almost 19 more years of life than if you lived in the most deprived. If the Victorian researcher Charles Booth were to rise from the grave to draw us some new poverty maps, he’d still need all those different coloured inks.

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One ailment, though, maintains a reputation for discriminating against the wealthy. Gout makes big toes swell painfully and cartoonishly. It causes chalky nodules called tophi — often compared to crustacean eyes — to balloon from knees and knuckles. It hurts. (“Like walking on my eyeballs,” reported the Regency cleric and humourist Sydney Smith.) The condition occurs when excessive amounts of uric acid in the blood cause crystalline needles of salt to gather in the joints and surrounding tissues. Its raw materials are purines — chemical compounds thickly concentrated in seafood, meat and alcohol — which helps to explain why gout gained its status as “the disease of kings.”

“Gout,” concluded Thomas Sydenham, one of the founders of British clinical medicine, “kills more rich men than poor, more wise than simple.”

Three centuries later, that’s no longer the case. The last big British study found that prevalence of gout in the population had increased by over 60% between 1997 and 2012. (Wales and the north-east of England were particularly afflicted.) In US, the “gout therapeutic market” is valued at $1847m, and a report released last month projected it might reach $3820m by 2027.

Thomas Sydenham might have looked at these figures and seen a strange and painful kind of social progress; a pathological levelling-up. In his day, only the wealthy could afford to surfeit on lampreys, pate and port. Perhaps, in 202o, cheap meat, cheap booze, the Iceland prawn ring and the two-metre long Aldi pig-in-a-blanket have made gout a disease to which anyone can aspire.

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The history of gout is as much about culture and class and morals as medicine. It’s a deep and uncomfortable history. Papyri discovered in the 1910s showed that the Egyptians had identified the condition by 2640 BC. In the 5th century BC, the physician Hippocrates referred to it as “the walking disease”. The name by which we know it calls back to the humoral theories of human biology that persisted from Ancient Greece to the early modern period. It comes from the Latin gutta (“drop”), and was first recorded by the 13th century by the French historian Geoffroi de Villehardouin, who asserted that the crusader Hugh IV of Saint-Pol had expired at Constantinople in 1205 because too much fluid — black bile, yellow bile, or phlegm — had spilled down into his legs.

Despite such horrors, gout conferred a kind of blessing. It was rarely fatal, and its presence in the body was thought to keep other, more deadly conditions at bay. “It prevents other illnesses and prolongs life,” argued Horace Walpole, “Could I cure the gout, should not I have a fever, a palsy, or an apoplexy?”

Surprisingly, for a condition that can turn your joints into throbbing satsumas of flesh, it was even considered sexy. Gout talk added a frisson to Benjamin Franklin’s flirty correspondence with Anne Louise Brillon de Jouy, a married harpsichordist he met in Paris in 1777. Franklin teased Brillon that had they consummated their relationship, his feet might be less painful in the night. (“If the ladies at Passy had more of that Christian charity which I have so often recommended to you, in vain, I would not have the gout now.”) She responded with a poem proposing the opposite: a man with “a pretty Mistress” — or two, or three, of four — was more likely to suffer. Franklin’s reply was to stay up late writing a short two-handed comedy in which the personification of his condition, Madame Gout, visits him in his chamber, rather as Fortune visits Boethius in Consolations of Philosophy.

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By GAVANNDRA HODGE

Novelists and politicians no longer feel the compulsion to turn their uric tortures into light literature. Despite the rise in cases, the discourse of gout has all but disappeared. And yet, the moral ideas that have circulated it since ancient times — its association with excess and indulgence — are still legible. They’re there, for instance, in Yorgos Lanthimos’s 2018 film The Favourite, in which the agonies suffered by Olivia Colman’s Queen Anne are attributable to her predilection for self-pity and stuffing herself with massive slices of cake. We see her engorged legs swaddled and smeared in therapeutic unguents. (We’re not told what these are, but one traditional remedy is advised: “Roast a fat old goose and stuff with chopped kittens, lard, incense, wax and flour of rye. This must all be eaten, and the dripping applied to the painful joints.”)

The outgoing Republican administration, though, should be given some credit for reviving gout as a moral metaphor — via the story of Paul Manafort, the disgraced chair of Trump’s 2016 election campaign. Manafort was convicted in August 2018 for lying his way to securing bank loans and evading taxes on the $16 million he earned as a lobbyist for pro-Russian politicians in Ukraine. His trial produced evidence of a fraud-funded life of eye-watering excess. His $15,000 ostrich-leather bomber jacket became a court exhibit. “The gluttony,” reflected the fashion critic of the Washington Post. “The indulgence. The preening bad taste.”

When he appeared for sentencing in October, he rolled into court in a wheelchair. His body was clad in a green prison jumpsuit labelled “ALEXANDRIA INMATE”, but his right foot was wrapped in bandages. His attorneys used his gout diagnosis as part of a plea for mercy. The judge, passing sentence the following March, was unmoved. “It is hard to overstate the number of lies and the amount of fraud and the extraordinary amount of money involved,” said US district judge Amy Berman Jackson. Manafort’s lies to Congress and to the American people, she observed, were perpetrated “not to support a family, but to sustain a lifestyle that was ostentatiously opulent and extravagantly lavish – more houses than a family can enjoy, more suits than one man can wear”.

Manafort sat in his wheelchair and listened in silence to the judgement. He wore a sober suit. His right foot remained bandaged. Its swollen condition became part of the story. Gout as an indicator of corruption? Gout as karma, perhaps?

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Too easy. Too satisfying. Champagne and foie gras can exacerbate an attack of gout, but if Manafort is a typical case, his condition is probably genetic. People who live on nut loaf and tap water are not immune and know its nocturnal agonies. The rise in gout’s prevalence in the UK and the US can’t be mapped onto any growth in the sale of purine-rich luxuries. Something more complex is happening.

Obesity is rising. The population is ageing. There are more people alive today in gout’s high-risk groups than there were in the days of Sydenham and Walpole. Let the law punish Paul Manafort, not the cultural backstory of the uric crystals giving his foot the Little Mermaid treatment. And let it bring justice for those others, too, who are enduring illness associated not with privilege, but its opposite.

They’re unsettling, disgusting things, threadworms: or they were to me, when I first came across them. But – luckily – they’re easily treated. A cheap, over-the-counter medicine, mebendazole, kills the lot. You have to dose the whole family, clean your linen, and dose again two weeks later, because the eggs (god, I’m shuddering just typing this) survive for a couple of weeks; but basically there is a simple, nuke-them-all-from-orbit cure.

Threadworms are just one species of intestinal worms, also known as helminths; there are hookworms, pinworms, tapeworms, whipworms, others. And they’re common — not just in north London, but around the world. The US Centres for Disease Control estimate that Ascaris lumbricoides is present in the intestinal tracts of about 1 billion people around the world. Usually, the infection has no symptoms, but in children it can lead to malnutrition, slow growth and impaired learning.

Luckily, again, these helminths can be killed with the same drug, mebendazole, or a related one, albendazole. Just as with the threadworms that cause itchy bottoms in the rich west, the Ascaris that cause childhood stunting in the developing world can be nuked, effectively and cheaply. A course of albendazole costs a few cents.

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Dosing someone who’s been diagnosed with helminths, then, is a no-brainer. It’s cheap and easy and effective. But over the past 20 years or so, there’s been a row going on about doing more than that: about giving the drugs to entire schools’ worth of children, regardless of whether they’ve been diagnosed with worms or not. 

In the late 1990s, two economists, Edward Miguel of Berkeley and Michael Kremer of Harvard, ran a study. They took 75 schools in Kenya, and gave albendazole to all the kids in 50 of them. Their results were impressive: absenteeism dropped by a quarter; children did better at school. The benefits also seemed to spread to nearby schools which hadn’t been treated, presumably by disrupting the spread of worms in the region. The whole thing cost $3.50 per pupil.

Where it got really interesting, though, was a follow-up study, a decade later. It found that the children in the schools not only did better at school — when they left school, the benefits continued. They earned more — about 15% more, on average — than those who had not been dosed. That is a huge benefit for a tiny cost. So everyone — including the WHO — got on board with deworming programmes. (Apparently, Cherie Blair even dressed up as a giant worm at Davos and chased people around.)

Then it all went a bit crazy. Two epidemiologists at the London School for Hygiene and Tropical Medicine reanalysed Michael and Kremer’s data, and found errors in the code, and some missing information, which led them to severely downgrade the findings: notably, the effect on surrounding schools disappeared. (It’s worth noting that there’s no suggestion of malpractice, and the LSHTM team and others have been full of praise with M&K for sharing their code and data so fully.) They also noted that the study wasn’t properly randomised or blinded. Then the well-respected Cochrane Collaboration released a report saying that there was little evidence that deworming programmes show benefit. Now a new study, again by M&K, claims that the economic benefits are still continuing.

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If you want to read about the whole saga, which came to be known as the Worm Wars, I recommend Tim Harford’s thoughtful take on it, and Ben Goldacre’s more sceptical one. There is a lot of back-and-forth, with defenders of M&K saying that the statistical techniques used by the LSHTM team made it almost impossible for the programmes to find a benefit. “To be quite frank, you have to throw so much crazy shit at Miguel-Kremer to make the result go away that I believe the result even more than when I started,” said one professor of public policy. On the other hand, one researcher into evidence-based charity told me “no one believes this but the economists”.

This all came up when I was writing my last book — which, somewhat incongruously, was about artificial intelligence, and whether it would destroy the human race. The two topics don’t necessarily seem connected, but they are.

The effective altruism community is a loosely affiliated group of people and organisations who try to find the best way of donating and spending charitable money, so it will do the most good in the world. For instance, imagine you want to help people who have visual impairment. You’re deciding whether to donate to a guide dog charity, or to a charity which provides surgery for trachoma in the developing world. As the effective altruism charity Giving What We Can points out, it costs about $50,000 to breed and train a guide dog, but you can restore many trachoma sufferer’s vision with an operation costing about $1,000. “For the same amount of money as training one guide dog to help one person,” they say, “we could instead cure about 50 cases of severe vision impairment.” That seems a fairly straightforward decision.

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Sometimes it’s not so clear. Is extending someone’s life by a year worth more or less than providing secondary education for a child? Is funding research into a Covid vaccine more or less effective than supporting democratic movements in authoritarian countries? But often, since most of us give to charity in fairly un-thought-through ways, it’s easy to improve the good we do. The simplest method is what William MacAskill, a professor of ethics at Oxford and founding member of the effective altruism movement, calls the “100x multiplier”: if you donate to a charity that works in the developing world, you can roughly expect to do 100 times as much good as if you donate to one that does a similar thing in the rich West. 

Effective altruist organisations such as GiveWell and Giving What We Can give lists of the most efficient charities to give to: the standout ones are about malaria. GiveWell estimates that roughly every $2,300 spent on bednets coated in insecticide will save one child’s life.

What I find interesting, though, is that both organisations recommend the Deworm the World Initiative and other deworming programmes. The effective altruism movement isn’t unaware of the Worm Wars controversy: GiveWell discusses it all in two lengthy, stats-heavy blog posts. They mention various reasons why the Cochrane review might have missed something — notably, it only looked at weight gain and school performance, not future earnings. But they also note that the children Miguel & Kremer’s research looked at had abnormally high levels of infestation, and that there are no obvious short-term mechanisms which could explain the long-term benefits — which should make us less confident that there’s anything real going on.

But they still recommend it — because, in short, they think the gamble is worth it.

There’s a concept in probability theory called “expected value”. That is, how much, on average, you can expect some action to return. Say someone offers to flip a coin with you: on heads they pay you £2, on tails you pay them £1. Your expected value is (2-1)/2, or 50p: if you played the game lots of times, you’d expect to make an average of 50p per throw.

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With deworming, effective altruists are doing exactly the same thing. There’s a strong possibility that deworming has no effect whatsoever on future earnings, or at least a hugely reduced one. But there is a small possibility that it has a huge, overwhelming impact, at a very low cost. The expected value of deworming — the impact multiplied by the probability, minus the cost — is huge, even taking into account the possibility that it doesn’t work at all. GiveWell assumes that its impact is 100 times less than the Miguel-Kremer study claims, and, even at that level, finds that it is cost-effective.

This is all very straightforward and I think most people would get on board with it. But the same reasoning leads you to stranger places, which is where AI comes in.

Nick Bostrom, the philosopher and AI researcher, points out in his book Superintelligence: Paths, Dangers, Strategies that there are a lot of humans who are yet to live. I discussed exactly how he works it out in an earlier post, so I won’t go over it again, but he ends up with 10^58 humans (one followed by 58 zeroes; a big number) before we run out of universe. That would be a very great positive — assuming that we think that human life is a positive thing, and that we would, all else being equal, prefer more happy lives than fewer.

So ensuring that humans don’t go extinct (a rogue AI or a bioengineered pandemic are considered the most likely ways that will happen) has a huge potential upside: quintillions and septillions of lives, unthinkably huge numbers. So even if there’s only a one-in-a-billion chance that he’s right, or one in 10 billion, it doesn’t matter. Those numbers are so huge that the expected value of anything that might improve the chance even by a fraction of a percent make the expected value — the benefit times the probability — spectacularly large. 

So, for large parts of the effective altruism community, the most effective way to do good in the world is to donate to organisations that will reduce the chance of an AI apocalypse, and to ensure that any superintelligent AIs we do build will work to help humanity survive, in a form that we would want.

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This sort of reasoning can take you to some very strange places, but it’d be too easy to wash your hands of it and say it’s all crazy. It’s not; if anything I rather admire the tendency to follow the reasoning where it leads, and not simply pull up short and say “OK now we’re getting weird.” My own instincts are that concern about existential risk is pretty sensible and that AI is a reasonably likely way that we could blow ourselves up. And most effective altruism is of the much more worldly, small-scale “antimalarial bed nets” calibre.

This latest Miguel/Kremer study, for what it’s worth, doesn’t seem to have shifted opinions much in the Worm Wars. The evidence-based charity researcher I spoke to points out that it is essentially a continuation of the previous studies, so all the problems that existed in the first studies are still there now. More than that, it follows the same group of people as the previous ones — it would be frankly weird if they had all suddenly become poor, after years of being richer.  “Same shit, different year,” the researcher said, succinctly. More importantly, this person says, there is a chance — which as far as I know has not been studied — that mass dosing with deworming drugs could cause worms to evolve a resistance to those drugs, like antibiotics create antibiotic-resistant bacteria. It is not inconceivable that the actual impact is negative, which would affect the calculations somewhat. 

Miguel Kremer, meanwhile, has won a Nobel prize in economics. “So we know who won the Worm Wars,” my source says. “I’m sure that will end all the arguments;” that last said with heavy sarcasm.

I’ve broken the omertà; if you don’t hear from me again, I’ve been silenced by the parent mafia. Only parents and developmental economists are allowed to talk about de-worming. But now you know how itchy bottoms relate to the AI apocalypse.