COVID-19, Editorial

Dealing With a Once-In-A-Century Pathogen

Back in 2015, Bill Gates published an editorial in the New England Journal of Medicine (NEJM) warning that the world would likely see a pandemic in the next 20 years. He was writing in the aftermath of the Ebola outbreak in Guinea, Sierra Leone, and Liberia, and argued that while the world had an effective system for containing Ebola, it did not have adequate preparation for dealing with a disease with a substantially higher transmission rate. “[O]f all the things that could kill more than 10 million people around the world, the most likely is an epidemic stemming from either natural causes or bioterrorism.”

Gates likened preparation for dealing with epidemics to preparation for another global threat—war:

The North Atlantic Treaty Organization (NATO) has a mobile unit that is ready to deploy quickly. Although the system is not perfect, NATO countries participate in joint exercises in which they work out logistics such as how fuel and food will be provided, what language they will speak, and what radio frequencies will be used. Few, if any, such measures are in place for response to an epidemic.

Two years later, at a global summit in Switzerland, Gates again warned leaders about their lack of readiness for a pandemic, emphasising that it was a global problem requiring countries to work together. “Epidemics don’t respect borders. And so, whether you’re looking at it through a humanitarian lens or a domestic lens, these are investments that should be made.”

In 2018, Gates made another warning. Noting that people can now travel across the globe in a matter of hours, he said that a pathogen similar to SARS could kill 30 million people in six months.


A new pathogen has now emerged. Coronavirus disease 2019 (COVID-19) was first detected in Wuhan, China in late December, 2019. As of March 2nd, 2020, more than 90,000 cases have been confirmed, and 70 countries have been affected, with the most serious outbreaks in mainland China, South Korea, Italy, and Iran. Over 2,900 people have died in China and 175 have died in other countries.

A study published in the Journal of the American Medical Association, assessing 72,000 reported cases in mainland China, estimates the virus to have a two percent fatality rate (rising to 49 percent in the critically ill), with an incubation period of one to 14 days. Around a quarter of patients develop a “severe” case requiring intensive care, and approximately 10 percent require mechanical ventilation. Symptoms include fever, dry cough, fatigue, headache, sore throat, abdominal pain, and diarrhoea.


The virus can be spread by people who are symptomless, it can kill the healthy as well as sick, and while not as deadly as SARS or MERS, it is more contagious, with a higher transmission rate.
 No vaccine is available. 

While the disease has spread to all corners of the globe, China appears to have recently seen a plateau, and possible decline in new cases. While we don’t know if all the numbers coming from the Chinese government are accurate, if it is the case that new cases have plateaued, it may be due to the rapid strategies deployed by the Chinese government to contain the outbreak.

A recent study led by Huaiyu Tian, Associate Professor at Beijing Normal University, has attempted to assess the effectiveness of transmission control measures used by China in response to the outbreak. Their analysis of 296 cities found that those which implemented control measures pre-emptively—before their first case of COVID-19 was reported—had 37 percent fewer cases of the disease compared with cities that took action after the first reported case.

What were these control measures? The suspension of public transport, closing of entertainment venues, and banning of public gatherings. 

Such measures are unlikely to be introduced in democratic societies. Writing in 2015, Gates noted that future epidemics would be harder to stop in liberal societies: “Because democratic countries try to avoid abridging individuals’ rights to travel and free assembly, they might be too slow to restrict activities that help spread disease.”

Yet past pandemics that have affected democratic nations can teach us lessons. In early October 1918, when the Spanish flu hit the east coast of the United States, the health commissioner of St Louis, Max Starkloff, ordered the closure of schools, movie theaters, saloons, sporting events and other public gathering spots. While the measures were protested by some citizens, the quarantine went ahead. A month later, as the pandemic raged on, he ordered the closure of all business, with a few exceptions, such as banks.

While drastic quarantine measures were being implemented in St Louis, the health commissioner of Philadelphia, Wilmer Krusen, gave permission for a parade for the war effort to go ahead in his city. It is reported that within 72 hours of the parade, every bed in Philadelphia’s 31 hospitals was filled, and in the week ending October 5th, 1918, 2,600 people in Philadelphia had died, with the figure almost doubling a week later. At the end of the outbreak, St Louis had the lowest recorded death rate in the US, while in Philadelphia mortuaries overflowed and “bodies [were] piled up on sidewalks.” 

It’s worth remembering that in an existential crisis, decisions need to be made on the basis of incomplete evidence. Measures implemented too early are deemed “alarmist,” if implemented too late, “negligent.” It is no different now than in 1918 when the Spanish flu hit. In his book More Deadly Than War: The Hidden History of the Spanish Flu and the First World War, historian Kenneth C Davis wrote:

Krusen’s decision to let the parade go on was based on two fears. He believed that a quarantine might cause a general panic. In fact, when city officials did close down public gatherings, the skeptical Philadelphia Inquirer chided the decision“Talk of cheerful things instead of disease,” urged the Inquirer on October 5. “The authorities seem to be going daft. What are they trying to do, scare everybody to death?”

The World Health Organisation (WHO) has recommended that early robust control measures are the key to saving lives and halting transmission of COVID-19. Worryingly, Robert Nelson, Managing Director and co-founder of ARCH Venture Partners, a biotech venture capital firm located in Seattle, San Francisco, and Chicago, has told Quillette that, in some places in the United States, it may already be too late: 

These bureaucrats and politicians who think panic is lines at Costco and angry parents when a school is closed, may find out that panic is when you are taking mom to the emergency room and she dies in the parking lot because no one can see her. I hope this does not happen and we get lucky, but all signs point the other direction. 

As a venture capitalist, Nelson’s job is to make bets on the future. With expertise in biomedicine his firm has invested in over 100 companies, 27 of which are valued in excess of $1 billion. On COVID-19, he said: 

The HUGE error now in [the] USA is being made by state and local health departments—they fear panic, so they are afraid to cancel public events and close schools. They are still waiting for symptomatic cases to act when we know there is huge asymptomatic spread. This is folly, and the expansion in places like Seattle will likely be uncontrollable. We must take more decisive action at state and local levels to immediately close schools and large gatherings and use social distancing, in order to flatten the curve. The reason that is so urgent is there is no way for our system to handle the critical and acute care burden unless we flatten the curve.

Quillette asked Jeffrey Flier, former Dean of Harvard Medical School what would happen to acute and critical care facilities if local governments did not get ahead of the virus. He said:

It’s all a matter of numbers—how many infected and how severe the consequent infections. At highest levels of both (still unclear where these will land), system could be overwhelmed, due to maxing out acute beds, illness of healthcare personnel, general supply disruption etc. and of course we have no therapy or vaccine yet. In that event, non pandemic healthcare would be disrupted and/ or postponed for some period.

Several CEOs in the tech industry are not waiting for local government leadership to implement self-distancing and are taking their own pre-emptive measures. Twitter CEO, Jack Dorsey, has ordered his 5,000 employees to work from home, while announcing that the company is suspending all non-critical business travel and events. Stripe CEO, Patrick Collison, has similarly encouraged, and in some cases mandated, remote work for his company’s employees. Just last month, the venture capital firm Andreessen Horowitz was criticised in the US press for discouraging handshakes inside its office, yet three weeks later the US military urged its own personnel to do the same. 

A few days ago, Gates published another editorial in the NEJM. Its message was clear:In the past week, Covid-19 has started behaving a lot like the once-in-a-century pathogen we’ve been worried about. I hope it’s not that bad, but we should assume it will be until we know otherwise.” 

In light of what we know—and acknowledging that our current information is still incomplete—our leaders must implement self-distancing policies now. While we must remain calm, the situation demands strong leadership and decisive action.

 

Claire Lehmann is the founding editor of Quillette. Follow her on Twitter @clairlemon.

Feature image: Health officers wearing masks and special protective suits take care of a patient infected by the coronavirus at a hospital in Tehran, Iran on March 2nd, 2020. The death toll from coronavirus in Iran has reached 66 as 12 more people lost their lives due to the disease and the total number of confirmed cases rose to 1,501. (Photo by Fatemeh Bahrami/Anadolu Agency via Getty Images)

Comments

  1. Well here in little old NZ we’re in a better position than almost every other country in the world to keep this disease out, but . . . the current government is sitting on its arse with almost nothing in the way of boarder checks, and almost nothing in the way of a strategy to prevent its spread when it does get here (we’ve one case but the family - more than the government - acted quickly) which is no surprise, this government is all show and no substance.

  2. There is nothing new about public official’s irrational fear and mistrust of the general population. In the thirties, there was a commonly held belief that the lower classes in urban environments would riot under sustained air bombing campaigns. In almost every area of human activity these fears prove unfounded. Almost. Because in every human there is the urge to hoard food and water, in the face of adversity, to hunker down and wait it out. It seems to exist inside us at an almost genetic level, and with good reason, because without this hoarding urge, it’s doubtful that our ancestors would have survived long enough to reproduce.

    Even in the modern age, these fears have ample justification. It’s a little known fact that only two days worth of supplies exist within our logistical systems in many areas of consumables. It’s why panic buying can have such disruptive effects. I would go ahead with the closing of unimportant offices, schools and public venues- it will have little effect on public morale. But where I would insist their should be more active intervention would be in the area of food supply.

    In the West, we have these marvellous systems of electronic ordering of food right to our very doors. They need to be expanded, possibly even by drafting in military personnel and volunteers.The process could be made even safer with the widespread issuing of hazmat suits to packing and delivery workers. It might be the case that deliveries to suspected contagious individuals might be made through zero contact drops, possibly temporarily requiring the greater use of plastic bags, but in a crisis every option needs to be considered. Many delivery drivers might need to use their own vehicles to cope with increased demand.

    All this might seem excessive, but I would argue that prudence and precaution are preferable to a lack of planning. There is an old military axiom which states that “amateurs worry about tactics, professionals worry about supply”.

  3. “Worryingly, Robert Nelson, Managing Director and co-founder of ARCH Venture Partners, a biotech venture capital firm located in Seattle, San Francisco, and Chicago, has told Quillette that, in some places in the United States, it may already be too late:”

    This seems like an crazy conclusion. The St. Louis shut-downs occurred in October of 2018, during the deadly second wave of the Spanish flu. The virus had already been around the world once and this was the second time. The coronavirus is nowhere near the same stage of spreading through the population as the Spanish flu when St. Louis took its steps. Timing is everything, and there is the economy to be considered. Many people were not paid in St. Louis for the better part of three months. Should or could the city have started that program eight months earlier and kept it up for a year? How about the entire nation? There is a balance to be struck.

  4. Authorities, experts and credible leaders for pathogens are scientists and public health professionals not billionaires, venture capitalists, Bill Gates and politicians. Your article is more alarmist because the majority of your sources are not motivated by public service that does not discriminate against poor people, but instead by people who perform brief works of charity and seek profit on the backs of suffering people instead of investing in long-term public health solutions. You ridicule bureaucrats and worship wealthy speculators.

    Genuine humanitarian goodwill and good science are constant and don’t suddenly appear once in a while as saviors. The real saviors are the dedicated nurses, doctors, medical research and public health professionals on the front lines of this virus, not the people you refer to in your silly article. Quote the medical experts in the trenches exposing themselves to the disease, not the speculators and billionaires.

  5. Symptoms include fever, dry cough, fatigue, headache, sore throat, abdominal pain, and diarrhoea.

    This describes pretty much the kind of cold or stomach virus people get all the time.

  6. What about the buses, or the subway? Should they kick people out of the supermarkets who cough too? What about people who walk on the sidewalk?

  7. image Image-1.png
    “A few days ago, Gates published another editorial in the NEJM. Its message was clear: “In the past week, Covid-19 has started behaving a lot like the once-in-a-century pathogen we’ve been worried about. I hope it’s not that bad, but we should assume it will be until we know otherwise.”

    And if it is not that bad what consequences will the hysterical alarmists suffer? Unlike the boy who cried wolf, nothing. Next out break they will be opining as if their missed forecasts never happened during the previous out break. People who spread conjecture, rumor and fear are almost as bad as the virus. Panic never solved anything. Let cooler heads prevail. A lot of these doomsayers are the same people who have declared China a worker’s paradise.

  8. Why should anyone “suffer” for preparing for a potentially dangerous global event? That’s ridiculous. Should I “suffer” for saving for retirement even though I might die too soon to enjoy it? Why would we ever punish anyone for preparing for the future?

    Your comment is very annoying to me.

    Also, your childish little meme is insane. No one is saying these diseases will “kill us all.” Last I heard coronavirus has a 2% mortality rate, that’s the “big one” we’re preparing for, not a 100% mortality rate. You’re sneering at an argument no one is making.

  9. I don’t see billionaire philanthropists and public health professionals, as being mutually exclusive as good people. Plus, it was ultimately free market enterprise and capitalism that raised over a billion people out of absolute poverty between 2000 and 2012, not Government- whose efforts with foreign aid over forty years barely scratched the surface.

  10. Your response reeks of hysteria. Take precautions and let the experts do their jobs. Don’t listen to billionaires, starlets, musicians or media talking heads. The chicken little alternative you appear to endorse is what is insane.

    “Your comment is very annoying to me.”

    Judging from your tone I would be willing to bet most rational things annoy you. Panicky people are always annoyed by the level headed.

    Perhaps you don’t remember being told 1:10 would die of AIDS, don’t go outside during the West Nile virus, cancel the Rio Olympics over Zika virus and the Over blown Ebola threat? Print and click media love those who panic and squirm. “Never let a crisis go to waste.” Why do you think Rob Emmanuel uttered that statement?

    https://inference-review.com/article/an-outbreak-of-epidemiological-hysteria

  11. I suppose Claire was also alarmed to find grocery stores in Sydney stripped of essential items yesterday. I pity those who waited too long to buy toilet paper!

    I think a point that is not sufficiently appreciated is that we go into every outbreak blind. We know some will be less deadly than the flu, and we know eventually we could get another Black Plague, but we can’t know which it will be at the time it is necessary to make decisions. Just because previous outbreaks were contained does not mean containment efforts are unnecessary: precisely the opposite.

    Something I wonder is whether individuals deciding to stay home as much as possible can limit the spread, in the absence of government fiat. If so, it becomes curious the Australian media has been calling Sydneysiders racist for avoiding Chinatown.

    I am currently sick, with only mild symptoms and no fever, but lab work scheduled several weeks ago and baby’s vaccinations lead me to spend 6 hours on ferries, trains, and buses this week. Do I have coronavirus? Should I have isolated myself? All of my concern about coronavirus did not prevent me from fulfilling work and parenting obligations. Is it realistic to expect individuals to preemptively self-isolate without widespread societal agreement it must be done? Perhaps this is one area we need the coordinated action government can provide.

  12. My honest feeling is that the hysteria surrounding COVID-19 would be nowhere near so profound if it had not first emerged in China. Deep down, even those who do not despise China for its communism are probably uncomfortably aware that the Chinese government is not above fudging numbers extensively to make itself look better and more in control. There are, as a result, very few numbers at the vital epicenter of this pandemic that we can trust – and that uncertainty has not declined with the spread of the disease to more reliable quarters.

  13. I am also replying to @Patrick (msg 18). It makes no sense to compare current figures for COVID-19 with the total figures of the Spanish Flu, because we have no idea yet what the total figures for COVID-19 will be. The doubling time for confirmed cases outside China is about half a week. See the charts at https://nucleuswealth.com/articles/updated-coronavirus-statistics-cases-deaths-mortality-rate/ .

    @AndrewG - downplaying the seriousness of this disease is like standing in a dessiccated eucalypt forest, with a 40C north wind blowing, and calmly observing that historically speaking, the flames 1km to the north are not as big as those of the average bushfire. You would be ignoring the fact that the fire is doubling in size every minute and that in 5 minutes. where you are standing will be an inferno.

    COVID-19 could easily be as bad as the Spanish Flu, per unit population, despite the advances of medicine, largely because hospital facilities would be overwhelmed by widespread disease like this. It could easily be far worse in total because all countries are linked by airline traffic, and the population of the Earth is 4 times what it was in 1919.

    https://www.nejm.org/doi/full/10.1056/NEJMp2002106

    We are now recognizing early stages of Covid-19 emergence in the form of growing and geographically expanding case totals, and there are alarming similarities between the two respiratory disease emergencies. Like pandemic influenza in 1918, Covid-19 is associated with respiratory spread, an undetermined percentage of infected people with presymptomatic or asymptomatic cases transmitting infection to others, and a high fatality rate.

    In late January I started a long thread on the medical and practical aspects of what is now almost a pandemic:

    That is where I will continue to discuss medical and practical matters. In this thread I will discuss the political, social and economic impact.

    Everyone should read this Vox interview with Bruce Aylward:

    Through country-wide (as far as I can tell) lockdown, education, thorough contact tracing and intensive medical care (oxygenating the blood outside the body, rather than or in addition to the mechanically damaging normal procedure of forced ventilation) China has decisively reversed the hyperbolic upward curve of confirmed cases and deaths. See msg 177 of the above thread for my analysis and quotes from the WHO report.

    Many Chinese and others blamed the Chinese government for allowing the virus to spread, initially, in and beyond Wuhan, in part by suppressing bad news and dissent, and allowing public events to go ahead. I think the government (CCP) is culpable in this respect, and in particular for allowing normally wild animals to be sold in markets. The CCP and other companies or bodies actively incouraged the farming and sale of these live animals for human consumption - even though such activities lead to SARS.

    There was talk of the people being so fed up with the CCP that its grip on power would weaken. But . . . look what we have here: declining new cases and deaths, certified as realistic by the WHO:

    The downward trend starting on 2020-01-23 is not at all what would have happened without intervention. The majority of the population everywhere still has no immunity to it. It remains to be seen how well the virus can be contained as the country emerges into partial productivity. If it gets out and about again, which would not surprise me, then the negative judgement on the CCP would persist.

    Far be it from me to laud the CCP, but the four weeks of downward curves shown here assuming it continues is the greatest justification I have ever seen for this particular dictatorship. Not every dictatorship could achieve this victory over such an infectious virus. The Chinese, as a people and as a nation, are frequently exceedingly smart, dedicated and hard working. But I think these qualities would not have been enough without the dictatorship pulling out all stops to combat the virus.

    They needed to, firstly to ensure their own survival as a party and government, and also, to protect the people of China, in order, in part, to protect the historic upwards trajectory of the country and its continued productivity and security.

    Iran is also a dictatorship, with bright and devoted people, with considerable resources. They had their period of inaction, as we in the West are having now, but the percentage of their population who are infected is very high, and I doubt they will have the success China has had in the past 4 weeks. (I don’t know how many people come from Iran to Australia, but two or more in the last week or so have been infected, and many Iranian MPs are infected too.)

    If democracies, including especially Hong Kong, Taiwan and Singapore, do not have the same success at battling this virus as the CCP has apparently achieved in the last 4 weeks - AND if that success is sustained, which I am not at all sure of - then how does this not count as a real arguments for the benefits of the CCP dictatorship? Their actions would be seen to have saved hundreds of thousands of lives compared to what would have occurred if only a democracy-style, Western-style, don’t-induce-panic-whatever-you-do response had been mounted instead.

    I expect the virus to achieve significant community spread in the West, including particularly the USA which I think has a very poor testing record so far, and where govenments are loath to shut down schools, business, transport and public events, such as the forthcoming Grand Prix in Melbourne. Then, hospitals will be overloaded and not everyone will get the treatment they need to reduce the Case Fatality Ratoi rate as China has done. Figure 4 from the WHO report https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf shows the CFR dropping drastically and continually to 20 February:

  14. This is a pretty common trend for respiratory viruses. There is an evolutionary trade-off between transmission efficiency and virulence. To kill you, the virus has to infect your lungs. But to infect your neighbor, it has to infect your nose/throat. Flus, for instance, seem to specialize in one or the other. I don’t know what the molecular mechanism is that would allow them to target lung vs. throat, but there appears to be one, and mutants favoring the throat will always outcompete those favoring the lungs. Thus, respiratory viruses tend to evolve to be less deadly over time.

    As of right now, the huge majority of Covid19 cases have been in China, so our estimate of the fatality rate is pretty much just the rate for the Chinese variety. My prediction is that the death rate will decrease with time.

    Another thing to keep in mind: the mass casualty pandemics of the past were driven as much by filth and general unhealthiness (and concomitant reduced immune function) as by the virulence of the pathogens themselves. Even the grossest third world s***hole today is cleaner than a typical European city in the 1400s.

    That being said, I’m still not shaking anybody’s hand for the time being, and have cancelled all travel through at least April.

  15. There are also some evolutionary concerns that make many viruses less lethal. For example, chickenpox hides in the peripheral nervous system for decades, then bursts out as shingles. It could just cross one synapse to get into the central nervous system, but since that would be almost certainly fatal, it doesn’t, because any that evolve the ability to do so kill their host and don’t spread. There are many other viruses where evolution limits their ability to kill, because those that don’t kill are able to spread far more than those that do.

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