Dire predictions about looming disasters are something that has gone on for a long time. My generation grew up under the atomic cloud. I was perhaps about ten years old when the leader of the now defunct Union of Soviet Socialist Republics (USSR) put a red circle around Peshawar.

This was of course due to the so called U-2 affair when a United States spy plane flew from a Pakistani airbase near Peshawar and was brought down over the USSR. The ‘red circle’ meant that the USSR had also aimed its nuclear missiles towards Pakistan.

Some sixty years later I still vividly remember the nightmares I had at that time about an atomic bomb going off in or around Lahore. Fortunately for us all, the US and the USSR kept up verbal bellicosity and proxy wars but never went on to a nuclear confrontation.

Then in the sixties there were dire predictions about impending global famines but now even with billions of people added to the world, international food supply has kept up with the growing population. Today famines might happen but they are limited to areas of warfare especially in the underdeveloped countries.

The ongoing looming disaster is of ‘climate-change’ due to global warming that may make our planet inhospitable to human life within a century or two. Whether humankind will be able to control or possibly learn to live with climate change remains to be seen. Personally, I will bet on human ingenuity to prevent extinction of the human race.

Now to more mundane dangers if not disasters. In the nineties we confronted the first major health crisis from a newly discovered disease that was initially deemed incurable. That was the HIV-AIDS epidemic. It is still ‘incurable’ but is now controllable and patients suffering from it can with appropriate medical help expect a virtually normal life span.

HIV-AIDS epidemic was the first major medical problem that was essentially self-inflicted. Its spread was stopped by enforcing preventive health measures and ‘safe-sex’ policies. Medical control came later. Since then we have had public healthcare scares like that of the Ebola Virus and in our part of the world, of the Dengue Fever.

Clearly we live in a world surrounded by bacteria and viruses so we must remain vigilant about new threats. Science fiction movies and novels teem with new and strange viruses that cause all sorts of damage from depopulation to zombie infestations. That said the greater danger at this time is from old foes that we thought were controlled.

Vaccines and vaccination has made this world a lot safer. Small pox is no longer a threat, polio is almost controlled. Things like measles and other such diseases are rare. All this has led to complacency and an anti-vaccination movement (anti-vaxxer) in the world.

In places like Pakistan the opposition to vaccination is based on ignorance more than anything else. People do not understand what vaccination is all about and in certain parts of the country vaccination is thought to be some sort of a conspiracy to make people sterile and local ‘leaders’ use religious reasons to oppose vaccination. Education can change that.

However in many western countries including the US, there is a growing anti-vaxxer movement. This movement as I mentioned above feels complacent about the benefits of vaccination but spreads exaggerated fears about the dangers through modern social media.

The complications of vaccines that the anti-vaxxers are most worried about are the least likely ones to be associated with vaccination. At least there is no proof of any such association. Of these the most prominent one that probably started off the anti-vaxxer movement was the fear that vaccinations somehow led to autism in children. No such relationship has ever been remotely established.

The anti-vaxxer movement has become sufficiently worrisome in the US that the New York Times published an entire editorial on how to counter the anti-vaxxer movement. ("How to inoculate against anti-vaxxers" -- NYT-January 19, 2019.)

Already there have been outbreaks in the US of preventable problems like measles and the anti-vaxxers have also been able to slow down vaccination against the Human Papilloma Virus that could essentially prevent most cases of cervical cancer in women. If the anti-vaxxer movement spreads, old enemies might start reappearing and that would be a problem.

Besides the anti-vaxxer movement, another major medical problem that is emerging is that of excessive and often inappropriate use of antibiotics leading to strains of dangerous bacteria that are now resistant to most antibiotics. A most alarming example was the emergence in Pakistan of a resistant strain of the bacteria that causes typhoid fever. Spread of these bacteria can cause a major healthcare crisis.

Another problem associated with excessive use of antibiotics is the effect on the human micro biome. Over the last few decades the importance of the bacteria and other microbes that normally live inside our bodies, especially in the intestines, has become established. Still experimental but a relationship between this micro biome and the rest of the human body including the brain has come under scrutiny.

Excessive and inappropriate use of antibiotics can damage and alter this micro biome and allow harmful organisms to flourish. There are some animal studies that even suggest that this micro biome and its changes might be responsible for many medical conditions including mental health problems and even dementia in older people.

These two problems can and probably will make certain diseases appear more often and others that will not be easily controlled. Not major catastrophes like the flu epidemic a century ago but serious enough to worry about.

The third thing I worry about is environmental pollution as a result of human activity. In the city of Lahore, reports keep emerging of arsenic in the ground water. Besides that we have the smog that covers us during at least two winter months every year. Forget about the other types of pollution, these two alone are sufficiently worrisome.

With these three problems medical emergencies will appear and already do. Global warming and climate change are also caused by human activity but the medical problems I have mentioned above are more immediate and can be controlled to some degree by local actions rather than international cooperation.

With modern rapid travel, any of the diseases that are antibiotic resistant or are caused by viruses that could be prevented by vaccination can spread rapidly all over the world even before they are clinically apparent.

If I remember there is already a ‘travel advisory’ about visiting Pakistan because of the antibiotic resistant typhoid. A couple of years ago we had a similar problem with polio and Pakistanis could only travel abroad if they took the polio vaccine.

It would indeed be sad if pulmonary tuberculosis (TB) reappeared as a public health problem but this time not treatable by all the antibiotics that used to work against it. The same could soon be true also of typhoid fever and other infections.

Fortunately many, if not all, of these problems can be controlled. But it will require major public health initiatives and a change in how we as physicians treat infections.