I live in a family of public health geeks. My kids used to ask me to tell them about a new deadly disease on each ride home from pre-school and had a collection of cute stuffed deadly viruses and bacteria, in addition to the usual assortment of stuffed animals. And for career day, I was the dad who showed up to elementary school in a full Ebola-level PPE suit and taught third graders about the role of art in public health.

Questionable parenting practices? Yeah. But our dinner conversations are amazing and spark the level of curiosity and appreciation in public health that I wish more people had, especially right now.

About three weeks ago, my kids saw that I was a little worried about something. Instead of telling them outright, I turned to our old game and asked them to tell me what they thought was the scariest disease.

Most people would go for Ebola because of its Hollywood-level freak out potential. Cholera is very scary as well, and an awful way to die. But my kids know by now that there’s one blue ribbon winner in my book when it comes to very scary diseases: Influenza.

Not garden-variety seasonal influenza. No, I’m talking about pandemic level influenza, like the 1918 pandemic flu that killed an estimated 50 million people and sickened a fifth of the world’s population.

This strain of influenza is the stuff of nightmares. A disease that spreads so rapidly that 2-3 healthy people could get infected by one sick person. A disease so deadly that it turns our own immune system against us, tricking it into a massive overreaction called a cytokine storm that either kills us or lays waste to our natural defenses so that that infections like bacterial pneumonia just waltz right into our bodies.

It’s why in 1918 the healthiest people often died the fastest: as in showing up for work in the morning and dead by night kind of fast. In places like Baltimore, Philadelphia, Seattle and countless corners of the world, the Great Influenza killed so quickly and debilitated people so widely that basic services broke down. In scenes reminiscent of Medieval times during the Bubonic Plague, when families were asked to bring out their dead, there were instances of bodies being stacked in the streets of America’s major cities.

And just like Bubonic Plague, where victims near death displayed the tell-tale, malodourous rash of “Ring around the Rosie” children’s song fame, care providers in 1918-19 watched as patients who were near death turned blue from oxygen failing to get through disease-ravaged lungs.

Here’s another little-known twist: Most people refer to the 1918-19 pandemic as the Spanish Influenza, assuming that was where it originated. But that’s not the case. Because of World War I, most of northern Europe was in a news blackout and didn’t report that thousands of soldiers engaged in fighting there were falling sick. Spain was the first European country to report on the emergence of the new disease, earning the unfortunate label as the epicenter for the pandemic.

There is general consensus among global health experts and historians that the true origin of the Spanish Influenza was likely thousands of miles away from Spain. It’s one of the many inconvenient truths that was glossed over in the midst of all the finger pointing and xenophobia directed to China during Covid-19: The deadliest plague in modern human history started just over a century ago not in a lab or a crowded urban tenement, but on a pig farm in the middle of Kansas, USA.

Which is why I’m watching the pigs now.

On October 29, the U.S. Department of Agriculture detected the first known transmission of H5N1 avian influenza to pigs on a small backyard farm in Oregon where poultry had been infected and euthanized recently. While certainly not a reason to panic, this milestone was alarming enough that I couldn’t disguise my concern during family dinner three weeks ago.

There are several reasons why we should all be keeping an eye on where H5N1 goes next.

First, think of pigs like a Vitamix for whirling around zoononic (animal) and human strains of influenza and spilling out the perfect pandemic-level smoothie. Because we share so much in common with pigs, genetically speaking, and because pork is such an integral part of the global diet, the potential for this animal species to serve as an efficient transmitter of deadly influenza strains is particularly high. This is worrisome, because H5N1 is very deadly to humans, carrying with it a 50+ percent fatality rate (compared to a roughly 1 percent case fatality ratio for Covid-19 among U.S. patients).

Second, if Americans are angry now about the price of eggs – which strangely no presidential candidate connected to mass chicken culls from H5N1 – just wait for the economic and food supply impact of broader infections among pig herds.

But most importantly, America’s public health system has been slow to track H5N1, ignoring important lessons from Covid-19 and downplaying the potential threat that could be on the horizon. There are broad concerns that surveillance has lagged and impacted flocks and herds are being undercounted. U.S. media attention has focused on the safety of the nation’s milk supply, which is interesting since pasteurization kills all viruses and bacteria (something to note for all of you raw milk drinkers out there). And there seems to be inexplicable foot dragging with our efforts to conduct and broadly share regular genetic sequencing of different H5N1 samples to understand how the virus may be mutating into a more virulent pathogen.

Instead of focusing on the infrastructure we have in place to detect a potential spillover of H5N1 to humans, we are poised to cut funding and resources needed to effectively track and contain outbreaks before they spread.

While pandemic fatigue is real and we can’t dismiss its influence on U.S. politics, economics or popular culture right now, we also cannot afford to leave our front door open when a virus with pandemic intentions is creeping around our yard.

Now is the time to review and publicly discuss the lessons learned from Covid-19 on surveillance, health system strengthening, rapid reporting and effective intra—government and public communications. We have more advanced technologies and biosecurity measures that we can leverage, as well as incentives to ensure livestock operators are not collateral damage in our war against disease. Lastly, we can’t afford to weaken routine immunization policies when they may be our first line of defense against a novel pathogen that overwhelms our health systems again.

By combining proactive policies with strong communication strategies, including more effective ways to engage and educate the media, we can effectively prevent and manage the threat posed by H5N1 and other pandemic influenza viruses, safeguarding public health and minimizing economic disruptions.

The question is whether there is enough political will remaining after Covid to keep our guard up against pandemic threats, either homegrown in the U.S. or originating in a far-off hot zone. The answer is what keeps me up at night.