The next pandemic will likely be caused by a virus against which we have no immunity. It will jump from an animal to a human, as around three in four new viruses do, in a place where the borders between the natural and the urbanised worlds have blurred into suburban sprawl, deforestation, industrial farming and climate change.
The virus will probably attack our respiratory systems and have a long incubation period, meaning the first human cases will become infected unknowingly, helping its potential spread before symptoms start to show.
If the first human cases are not found in Australia, emerging from a cross-species infection between a native carrier and an introduced intermediary animal, like a horse, or through our agricultural industry among the more intensely farmed animals like pigs and chickens, then they will arrive on an aeroplane, probably bound for a tourism destination.
The virus' natural carrier will be a bat. Bats account for one in every five mammals on earth and are found everywhere. They are highly mobile, exceptional carriers of viruses, and can live close to humans, particularly in cases where their colonies have been displaced. In the last 20 years, bats have been linked to several high-impact outbreaks, including SARS coronaviruses like COVID-19, Hendra, Ebola, MERS and Nipah virus, and by some estimates, represent the largest known reservoir of emerging viruses.
The outbreak will be hardest on marginalised communities with known immunity compromises, those who are socially excluded or face economic insecurity, and areas where the availability of healthcare is scarce.
When the first cases arrive, governments will scramble as the arbitrary dividing lines of politics and party erode into irrelevance.
Hospitals will come under pressure. Patients will die.
The medical research sector will pivot, using its collected data to map and profile the virus, develop models for how it spreads, and race to find a treatment.
Amid the fear and existential dread, the public will have to negotiate misinformation that spreads as quickly as the disease. There will be concern about the effectiveness of treatments and uncertainty about how to prepare and survive.
When the dust settles and the tallies are taken of the sick and the dead, there will be strong calls for better funding to fast-track vaccine clinical trials, a broader research and development scope to better understand how viruses jump from animal to human, and better models for personal protective equipment.
Community health engagement efforts will foster public trust in good science and call for more participation in research to learn the lessons we need to learn to be better prepared next time.
The next pandemic is coming, and so is the one after that. If this narrative sounds familiar, it's because it is.
About three years before the first cases of COVID-19 were detected, foreshadowing a generation-defining global pandemic, this was largely the lesson learnt from the West African Ebola outbreak of 2014 that killed more than 11,000 people, including 518 healthcare workers.
In the aftermath of that health emergency, the medical sector found it had been caught off-guard and was ill-prepared to cope with the spread of a virus for which it had no vaccine, no drugs for treatment, few medical teams and frontline responders equipped to fight it, and no specifically targeted public education campaigns to guide and reinforce the response.
In 2017, the World Health Organization's retrospective on the Ebola outbreak set out a blueprint for empowering research and development to prevent future epidemics and save lives.
It has been almost five years since the first cases of COVID-19 emerged in China in December 2019. Human-to-human transmission followed quickly. The virus became airborne, and in January 2020, Victorian health authorities confirmed the first case had arrived in Australia on an international flight to Melbourne. The dominoes were beginning to fall.
'You can't see them, but they are everywhere'
As the first COVID cases spread and eventually infected the Hunter health district, the virologist, Nathan Bartlett, found himself in the rare space of seeing what would become the modern history of his research written in real-time.
As case numbers soared, lockdowns were imposed, and the healthcare sector rapidly mobilised to treat those who became infected, Dr Bartlett and the researchers around him were thrust into the frontlines of the nation's defence.
"I'm fairly pragmatic about it," he says. "This is the way that research goes. It just so happens that what I work on became very important because it was a global pandemic. I just do my job."
Dr Bartlett remembers when what would become a career pursuit in studying viruses distilled itself in his mind. He had always been interested in medicine but thought a career as a doctor wasn't suited to him. He was more interested in research, learning how viruses spread and replicate, studying the parts of the body they attack, and observing how they adapt and mutate for survival.
"When I thought about the diseases that I made a career out of, infection and viruses seemed like a cool thing to study," he says. "You can't see them, but they are around everywhere. That was what I always wanted to do."
As an undergraduate, he spent a summer working at the Australian Centre for Disease Preparedness in Victoria, the CSIRO's high-containment facility, where researchers work with the world's most dangerous and infectious agents to protect the national biodiversity and farming industries from potentially devastating outbreaks. It was where Dr Bartlett found his calling.
"I could see in the window the guys in there doing that work, and I just thought I wanted to do that one day. It was that old adage that you can't be what you can't see," he says. "Well, I could see that because I was lucky enough to get a summer placement in that laboratory, and it inspired me."
He took a post-doctorate position in the UK at Oxford University and later at the Imperial College London, where his interest turned towards respiratory viruses. He eventually returned to Australia in 2015 to lead the University of Newcastle's viral immunology and respiratory disease group.
He was recognised as Newcastle's 2024 Citizen of the Year for his work and response during the COVID pandemic.
'Not the apocalypse I prepared for'
When she reflects on the last pandemic, the director of the Hunter Medical Research Institute, Frances Kay-Lambkin, recalls the dissonance of the moment when the theoretical world of research suddenly clashed with the realities of the day's war against the virus.
"It was an existential crisis," she says. "We had trust in our health department and government, and we saw them scrambling, revising, and changing all the time, which we don't often see. We saw the emotion and stress playing out on their faces. It's not that we don't trust, but it felt like the first time the government didn't know what was going on, and they were doing the best they could."
"I think, as researchers, that is the environment we work in - with uncertainty and testing and revising - but for most people, that was totally foreign. At the same time, our government was taking away some of our civil liberties - the rights to hug grandparents - and, of course, we understood why - we had to do it, but it was this awful situation."
She describes it as a "glimpse behind the curtain in a life or death situation".
"They were asking us to trust them when it was clear that no one knew what was going on. It wasn't the apocalypse I prepared for."
On the ground, frontline healthcare workers raced to keep ahead of developments and new advice that changed almost daily.
"I would talk to nurses who had reorganised an entire emergency department, and then two days later, there would be a new piece of evidence, and they would have to do it all again," the NSW Nurses and Midwives Association's general secretary, Shaye Candish, says. "When you work in healthcare, you expect practice to evolve constantly - you're always looking for continuous improvement. It's built into the DNA of health practitioners."
"The speed at which it was happening, though, did generate some whiplash, and it was around the organisation and reorganisation of the work that had to happen. How do you actually test differently when you only have an x-type of swab and you need a y-type? How do you make that happen?"
"When COVID first started to appear, there wasn't a lot of knowledge around how it was transmitted, so people were taking fairly standard precautions around protective equipment, but we didn't have enough. How do you prevent the transmission of a virus when you can't protect yourself from it? What can you use? And what happens if you don't have the right-sized gloves or mask?"
Where the health network came into its own was the relative speed at which it was able to mobilise its researchers and staff as seemingly disparate sectors turned toward the immediate problem at hand. The Hunter's engineering outfit, Ampcontrol, primarily an energy sector manufacturer, began building ventilators. Earp Distilling Co began making hand sanitiser from alcohol byproducts. It was a drop-everything moment.
"We weren't even thinking about treatment, I think, at that point," Dr Kay-Lambkin says. "What resources did we have that we could mobilise, or could we drop everything and focus?"
Still, as the advice and evidence changed daily, public confidence in the effectiveness of the response - and patience with the draconian measures taken to prevent the spread of the virus - ran thin.
"The way we talk in science and medicine is not in absolutes," Dr Kay-Lambkin says. "'It could be this, or maybe that. There probably will be another pandemic'. That doesn't sound very convincing or helpful to people who aren't used to thinking that way."
"That's also what we saw our government doing. I think what we had to do - and probably the big lesson learnt for us - was to be absolute in what we thought would work in times when people couldn't entertain the grey."
"Make a decision, and be absolute about it because then there is no ambiguity. At a time when there is chaos and stress, that is the way to get the cut-through message."
There are no silver bullets
How do you prove that you have just averted a national health emergency? By definition of success, there is no health emergency to point to that can be leveraged for better funding to support research, accelerate the development of new drugs and vaccines, and pay for public outreach and education campaigns that capture the most vulnerable and those most distant from interactions with the medical establishment.
"When we went from having no vaccine for COVID-19 to vaccines in arms in 18 months, the public thought what kind of voodoo magic has gone on," Dr Kay-Lambkin says. "What corners have been cut? Actually, this is what happens when science is funded with a focus. I think that is part of what might have helped acceptance of the vaccine - if it wasn't seen as magical."
"I can't help but think that if we were proactive about the scientific method, the only thing that stops us from making discoveries quicker is funding."
In his laboratory on the sprawling John Hunter Hospital campus, Dr Bartlett works with cells collected during respiratory medical and diagnostic procedures to learn how viruses gain purchase as they transmit, what parts of the body they attack first, and how we can defend against them.
His research has guided the development of a nasal spray designed to reduce the risk of a virus like COVID-19 spreading from the nose, mouth and throat into the lungs and escalating into serious illness.
"The science we do should have an impact and put benefit into the hands of people in the real world," he says.
COVID-19 caused 667 deaths in the six months from January to June this year. It was the highest number of fatalities since January 2023. In the 28 days from August 19 to September 15, the World Health Organization counted 89 countries with reported COVID cases, 31 of which had recorded deaths. Long COVID continues to burden health systems around the world as around six per cent of those infected who show symptoms are suffering its effects.
Vaccination rates have declined each quarter from 2021, according to WHO data, such that only six million people had received at least one dose from January to March this year among reporting nations compared to more than 1.7 billion at the height of the outbreak.
By all accounts, even as we return to lives that resemble the time before the years that have collectively come to be called 'the pandemic', COVID-19 represents an ongoing health emergency.
"Watching a new virus simultaneously infect the world - I will never see that again, hopefully," Dr Bartlett says. "I'm in my 50s now, so maybe I won't have to see that again, but who knows?"
"We had all these preconceptions, and we got a lot of it very wrong, to be honest. This virus was supposed to be gone by now. If you look at Spanish flu, there were two or three seasons, and it basically wore itself out. This virus is very stubborn, and it keeps finding ways of evolving and spiking in new waves. We didn't expect that. No one expected that."
The probability of the next outbreak is an eventual certainty. It may not be a global, generation-defining event, but a significant health crisis in a handful of nations in a geographical region on the scale of MERS and SARS, Ebola and the current response to Mpox.
Preventing the spread of those hypothetical future agents and developing treatments is a wicked problem.
Even in the war game of a bat-borne viral pandemic, solutions are not as clear-cut as they may appear. The same innate immunity that bats have developed to often carry multiple viruses without showing signs of clinical illness - the metaphorical black powder of an outbreak - could prove a viable pathway to fighting the potential pandemic it could ignite.
In the aftermath of the COVID years, the interim Australian Centre of Disease Control adopted the WHO's 'one health' approach to preventing future pandemics, recognising that the health of humans, animals, their various ecosystems, and the economies that rely on them are intrinsically interconnected. To remove or disrupt one would be to risk the health of the whole.
"One health is not a new concept (but) it has become more important as the pressure on global ecosystems has increased due to human population growth, international travel, habitat destruction and the effects of climate change," the CDC says.
Some 60 per cent of emerging infectious diseases globally have come from animals. More than 30 of the newest human pathogens have been found in as many years, three in every four of which have originated in animal species.
Frontline health workers say they are less concerned about the prospect of an evolving understanding of emergency outbreaks and more about the event's impact on their daily work and conditions.
Before the pandemic, "it was not uncommon to see a very sick nurse at work, trying to look after a patient," Ms Candish says. "I think, these days, there is more awareness that if you have a cough or a cold, you should stay at home. And we have seen an uptick in sick leave use. But, nurses don't have a lot of sick leave, even though they deal with sick people every day."
"We're in a situation where nurses have less sick leave than teachers, but historically, they haven't really taken it. Now, a third of the workforce doesn't have any sick leave. That is something that needs to catch up."
Most hospitals undertake regular risk management and preparations for major events, but many of these have traditionally focussed on mass trauma response - a terror attack, for example.
"What the evidence talks to, much more clearly, is that the risks really relate to these types of infection processes - a pandemic," Ms Candish says. "That internal planning and preparedness is critical. Having a system that is agile and able to evolve as quickly as our system did is why we were able to weather that pandemic."
That agility came largely from centralised data and information sharing across sectors that allowed frontline healthcare workers to keep pace with the outbreak and its unpredictable turns.
"When we had information, we were able to be a couple of steps ahead," Ms Candish says. "When we were in lockdown, that allowed the workforce to be a couple of steps ahead. It was never going to stop the pandemic, it was never going to be the silver bullet, but it allowed us to save the lives that we were able to save."
'A human behaviour story'
What is the thread that connects suburban sprawl in the US state of Connecticut in the 1980s, the proximity of the Australian equine industry with native flying fox colonies, the age of a commercially farmed pig when it is slaughtered, and a wildlife market overseas trading in exotic native and introduced species? They are weights on the scale.
Taken in isolation, these occurrences seem insignificant: the daily activities of communities, regions and national economies. But, they are the incremental shifts that bring the probability of cross-species outbreaks closer to the inevitable.
The bacteria that causes Lyme disease was found in Connecticut around 1982, where suburbanisation had driven out predators of the agent's natural carrier - the white-footed mouse - dramatically increasing the probability of the disease transferring to ticks and then to humans until the spillover invariably happened.
In September 1994, a prominent Queensland horse trainer and 14 of his horses died after suddenly falling ill with a mysterious disease that would later be identified as the first human case of Hendra virus, transferred from the native flying fox to horses and then to humans.
Juvenile pigs, like humans, are more susceptible to disease than adults because piglets have not yet developed antibodies to fight infection. Of the five million pigs slaughtered annually in Australia, almost none live longer than a year, effectively creating a vast population of genetically similar animals living in close proximity and perpetually of the age when they are more susceptible to infection.
None of these events goes unchecked by strict and expansive biodiversity laws, industry regulation, and ongoing preventative research, but they are the pedestrian human activities - the daily undertakings both small and industrial in estimation - that thumb the scales of a potential outbreak.
"These are all playing into the hands of a virus getting into humans that shouldn't be in humans," Dr Bartlett says. "It is the sequence of events, the conditions, for a virus to gain a foothold in the first humans it infects, and then slowly adapt and become more transmissible. And then you get something like COVID."
"It is a human behaviour story - the virus was given an opportunity because of human behaviour. Simple as that. That behaviour affects the climate, how we interact with animals, and how we travel around the world and interact with each other."
Dr Kay-Lambkin has taken to thinking of such outbreaks and their probabilities as similar to the idea of cybersecurity.
"We are all being encouraged to understand that we can't prevent an attack or a breach - we have to accept that - and it is not a good use of resources, time and effort (to wholly prevent them). Of course, we can try, but the effort and the focus really needs to be on how quickly we will detect them when they occur and how quickly we can mobilise to stop them from progressing."
"That is not just in terms of health - our whole society needs to mobilise around these sorts of issues."
Dr Bartlett similarly balances the natural desire for and the practicalities of being in control of the wicked problem, balancing the social and personal responsibilities of preparing for and trying to prevent the next outbreak.
"It is a global issue," he says. "We cannot control what is happening around deforestation in Brazil, or in China, or sub-Saharan Africa. In Australia, we have zero control over that."
"I have been thinking about this a lot. The way that we think about disease is very personal. We say 'your cancer journey', 'your disease'. And, generally speaking, your disease is very personal - it affects you and perhaps those who are very close to you. We don't think about it as a societal issue. Thinking about a disease on a societal level in that 'you' might not have cancer, but there are things that you can do to help."
Dr Kay-Lambkin picks up the thread: "The frustration that I have often is that we tend to sit and not act until we have the perfect solution."
"Or that it is someone else's problem and they will solve it," Dr Bartlett adds.
"And I will wait to receive instruction," Dr Kay-Lambkin says. "But I think, in terms of agency, there are small things that we can do. And if we all did a little bit ..."
