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 Chinese CDC today published the largest case series to date of #COVID19 in mainland China (72 314 cases through 2/11/20). Here are some of the data:
• 2.3% Overall
• 14.8% age >= 80
• 8.0% age 70-79
• 49.0% in critical caseshttps://t.co/ZFR6pScCpa
— JAMA (@JAMA_current) February 24, 2020
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)