It’s March 2020, and as I write this piece- the world faces a profound health-emergency. The COVID-19 coronavirus (SARS-CoV-2) has been declared a pandemic, and is quickly spreading across our hyper-connected world.
As of today (09th April 2020) over 3 billion people are locked-down around the world, close to 1.51 million cases have been confirmed worldwide and almost 91,000 lives have been lost (it is fair to say these estimates may be conservative). The data are changing on an hourly basis and the consensus in many nations is that they can no longer contain the virus and are simply working to slow it down, thus avoiding the swamping of already overstretched health systems.
Dr. Tedros Adhanom, Director General of the World Health Organisation noted in a recent speech that, “Our message to countries continues to be: you must take a comprehensive approach. Not testing alone. Not contact tracing alone. Not quarantine alone. Not social distancing alone. Do it all. Any country that looks at the experience of other countries with large epidemics and thinks ‘that won’t happen to us’ is making a deadly mistake. It can happen to any country…”
This shouldn’t have been a surprise, experts have been warning us this is coming, and we’ve been here before. The 1918 influenza pandemic (known as Spanish flu) was the first of the two H1N1 influenza outbreaks (the second being the 2009, Swine flu outbreak). The Spanish flu infected 500 million people (around 27% of the 1918 world population), killing 50-100 million people.
To learn more about the 2020 SARS-CoV-2 (COVID-19) ‘Coronavirus’ pandemic, and to learn more about what we can do now, and in the future, to respond to virus outbreaks, and pandemics, I spoke to two of the world’s foremost experts: Professor John Oxford (The UK’s top expert on influenza and Emeritus Professor of Virology at the University of London), Prof. Christian Bréchot (Professor at the University of South Florida and President of the Global Virus Network), Professor Harish Nair (Professor & leader of Respiratory Viral Epidemiology research programme, University of Edinburgh), Dr. Roberto Consentini (Emergency Medicine Chief of the Papa Giovanni XXIII hospital in Bergamo), Michael T. Osterholm (Director of the Center for Infectious Disease Research and Policy CIDRAP), Gideon Lichfield (Editor in Chief, MIT Technology Review), Yonden Lhatoo (Chief News Editor, South China Morning Post, in a personal capacity), Trish Greenhalgh (Professor of Primary Care Health Sciences, University of Oxford), Professor Matt Strauss (Former Medical Director of Critical Care at Guelph Hospital, Canada & Asst. Professor at Queens University), Dr. Zaher Sahloul (President of MedGlobal & Critical Care Doctor) and Vincent Racaniello (Professor of Microbiology & Immunology, College of Physicians and Surgeons of Columbia University).
Q: Why has the world been so poorly prepared for a pandemic?
[Professor Michael Osterholm]: The world lacks creative imagination when it comes to mother nature- we believe that we have the power to bend nature to our desires and forget that we’re vulnerable. Nature is a combination of biology, physics and chemistry- they are collectively much stronger at bending the will of the world than we are. We don’t understand the power of nature. We see hurricanes often, so we understand them… We understand the power of earthquakes, because we experience them every year. We didn’t understand a pandemic with all the right circumstances.
[Gideon Lichfield]: We should have seen this coming, and some people did. I’ve been speaking to public health experts, former CDC advisors, and we know that planning exercises and discussions around a pandemic were held in the USA; but not publicised. These exercises concluded that the US was underprepared- but nothing was done to improve preparations.
The experts knew this was coming, but as government, society and business… and as people… we were not geared-up, and it seems memory is short. Nobody remembers the 1918 flu pandemic, and recent outbreaks like SARS and MERS were relatively localised. The Swine Flu infected something like 60 million people in the US, but it wasn’t that severe as to cause a crush on the health system.
It’s a roll of the dice whenever one of these novel viruses emerges; sometimes they will be severe and contagious enough to cause a problem, and this one is.
Q: How prepared was primary care for this pandemic?
[Professor Trish Greenhalgh]: Primary care was not prepared for this pandemic; it’s not what primary care is set-up to do, so we have to be careful we don’t start blaming primary care for not being set-up. I went to medical school in 1977, graduated in 1983 – back in the 70s, the kind of diseases you were taught to deal with were chronic, non-communicable diseases. Just after I qualified, HIV emerged – the world got on-top if it relatively quickly, but it wasn’t contagious. As Julian Tudor-Hart said, ‘primary care is good at doing simple things well, for large numbers of people, few of whom feel ill…’ – but now we’re in a situation where a lot of people are feeling ill – either because they’re worried about having COVID, or because they have COVID.
We’re dealing with a highly contagious disease, so contagious that it’s causing the biggest change to workflow that the NHS has ever experienced. Just to give you one example; I’ve been working on video-consultations for over 1 years – we’ve been working with one particular hospital trust – and it’s taken us 3 years to get from one clinical service, to 15. Last week I was asked to help the NHS get video-consultations up and running in every GP practice in the country, in one week.
Q: What are your views on how China *first reacted* to the Covid-19 outbreak?
[Yonden Lhatoo] They could and should surely have done better. There’s obviously been a fair amount of bungling and covering up on the local level, with cadres and bureaucrats muzzling health care professionals who first raised the alarm about a mysterious pneumonia-like illness that was killing people in Wuhan.
Also, China’s system of releasing such information only with approval from higher up the political chain, with local officials having to wait for the central government’s authorisation, can be blamed for the delay in reporting the outbreak.
Those who criticise China have a case to complain about the contributory role the country’s authoritarian system played in the spread of the pandemic, but that very system also allowed authorities to get a quick grip on it and bring it under control with impressive efficiency and mass effort.
The “they should have given us enough warning” defence that US President Donald Trump has been using as Western nations now struggle with an explosion of infections is a bit disingenuous, given that they all had more than two months to watch people fall sick and die in this part of the world, and to think that maybe they should really do something to protect themselves.
Q: How serious is our current pandemic?
[Professor Michael Osterholm]: This virus is not only causing severe disease and death, but it has rewritten the entire political, economic and social landscape of the world. We’re all going to die, there will always be a top 10 causes of death, what we haven’t understood is that this is a situation where we will die from a disease that frightens people… is mysterious to people… These are different kinds of deaths- the world fears this kind of death. We are experiencing now what it must have felt like in the middle-ages to have plague rip through your village.
What kills us versus what hurts us versus what scares us can all be very different.
Q: What are critical care doctors seeing at the front-line of the COVID pandemic?
[Dr. Zaher Sahloul]: I’ve been a critical care specialist in Chicago for 25 years, and what we’re seeing is overwhelming. I work across several hospitals- one is a tertiary centre with 140 ITU beds and 240 ventilators, and some are small ‘safety net’ hospitals that work with underserved communities. In the last few weeks- we have been transformed because of the COVID-19 pandemic. More than 80% of all emergency room admits in the last week are COVID patients; some are coming very sick, and require transfer to ITU and ventilation. Some have moderate symptoms, but practically all our resources have been directed to COVID as these patients require oxygen, ventilation, specialised nurses, respiratory therapists, doctors, expensive medication and stay in ITU for longer. Unfortunately, despite the care we can provide – many patients are dying.
Frankly, our hospital looks like a war zone- we are opening more floors to become temporary intensive care units, getting more ventilators ready, doubling patients in rooms, and even considering connecting one, two or even three patients to a single ventilator. Even in the USA, we do not have unlimited supplies, and healthcare workers have been exposed to COVID-19 because of the lack of proper PPE. We have had many incidents in my hospital with doctors and nurses who have been infected- and who are now in self-isolation or quarantine. Across the United States, we have had several deaths of doctors and nurses who are caring for corona patients. This is a truly exceptional period.
Q: How is the coronavirus situation in Italy- the heart of the European outbreak?
[Dr. Roberto Consentini]: Here in Bergamo, we are still at the peak of the outbreak that started on the 21st of February. At our hospital, in the first week- we had 10-20 patients admitted per day, and that rose exponentially to where we are today, at 60-70 patients admitted per day at our hospital.
We have had to completely reorganise our hospital, from the emergency room through to ICU, semi-intensive and high dependency. We’ve converted as many beds as we can into covid beds. Our emergency room has had to create a three-level triage, stratifying patients into groups of acuity; high (intubated), intermediate (non invasive respiratory assistance) and low acuity (patients with pneumonia who still need oxygen). We now have a huge ICU with upto 80 beds for covid patients, and there are more than 100 patients on non-invasive patients on our ward.
Q: What is the age profile of patients you are receiving?
[Dr. Roberto Consentini]: The first patients with pneumonia that we saw in our emergency department were older patients- in general older than 80- with co-morbidities such as diabetes, hypertension or obesity. In the last 10 days, the mean-age has started to decrease, and we now see patients in the age-range of 40-60, and that’s not good.
Q: How do viruses jump from animals to humans?
[Professor John Oxford]: It’s not easy for a virus to spread from a bat to human (as we think COVID-19 did). It most probably spread from a bat, to a civet, to an anteater to a human- each jump being difficult. Viruses don’t want to jump species, they’re quite happy where they are- being in a bat is wonderful, they’re having a good time, causing no harm, and spreading easily. Jumping into humans will cause all sorts of issues for the virus, it will have to mutate… to evolve… bit by bit, and these mutations allow them to jump between species on the rare occasions where the conditions are just right – so – a civet cat may have been around a bat with the right mutated virus, the cat got infected, a human comes along… buys that cat, chops its head off… takes it home for dinner… that’s when they probably got infected… handling these animals. These are rare events, and that’s jolly fortunate.
We are going to have a lot more surveillance on our food systems now however, and in particular on the kind of markets where the behaviour and proximity make these viral jumps more likely. China is a superpower scientifically, economically, but has a weakness- the population is still very keen on special foods. They don’t need to eat these animals, it’s for culinary delight. At some point, these practices will have to be monitored closely or stopped – otherwise we’re going to face these viruses again and again.
Importantly; we don’t want a blame game here. We’re already hearing the USA thinks China is to blame… and we have to stop this finger-pointing. In 1918, we had 50-100 million killed by Spanish flu which allegedly emerged in Kansas. All the evidence I’ve got shows that this virus came from the Western Front in the great army camps. Half of Britain’s medical, scientific and nursing staff were on the Western Front – not at home in England. They had 175,000 beds along the Western Front, it was huge. Alexander Flemming was there. Out of all that, emerged the 1918 flu- it had an opportunity to move about these closely packed people. It wasn’t American, it wasn’t Spanish…. and we cannot play those kind of blame-games as it stops us from working together, as we should.
Q: How good are we at detecting viruses early?
[Professor Christian Bréchot]: Since the first SARS outbreak, we have witnessed a huge improvement in global health security. Global health and health security have been pushed higher up the political agenda at the UN and G7, and the WHO has made significant improvements.
We have seen the improvements to surveillance and communications first-hand with the outbreaks of Ebola. At the beginning, it was a mess but we brought Ebola under control well.
Having said that, I still do not think the world is adequately prepared- particularly around diagnostics. Diagnostics are really the heart of controlling an epidemic. If you are able- really early in the first phased of an epidemic- to identify individuals, check them, and isolate where necessary, you can control an epidemic.
What we are witnessing now is a lack of diagnostic tests, and political hurdles in China, the US and other nations. There is an unfortunate blend of a lack of diagnostics, and a lack of political will to rapidly curb epidemics.
We have made significant improvements in the past 20 years, and there is a lot of promise for the future, but we need to recognise that we have underappreciated the importance of diagnostics, and focussed too much on vaccines and therapeutics.
Now, I want to be clear – vaccines and therapeutics are very important. I am not saying that we should not work on this… but what I am emphasising is that we must include diagnostics to the level of priority as vaccines and therapeutics.
[Professor Michael Osterholm]: We are seeing ‘hotspots’ appearing wherever the virus has had time to penetrate into society. Many of these hotspots are not unique geographically, or because of the people, but they are unique because the virus has transmitted over 8-10 generations before it is detected.
Imagine you had a fire in your kitchen- you may put the fire out and feel good about yourself, but the fire is also in the wall behind the kitchen and a few minutes later? Your house goes up in flames.
When you have this transmission that you don’t recognise early enough- by the time you pick it up, it’s really severe. We’re dealing with that kind of situation now.
[Vincent Racaniello]: This could have been a lot worse, it could have been an Ebola-like virus that started transmitting like this. Virologists have always known there was potential for this, we’ve known for years. This will not be the last one, there will be a SARS-CoV-3, a SARS-CoV-4… they won’t just come from bats, they’ll come from other animals, and we need to be ready. We already have the tools. We had a science program that looked for viruses in exotic creatures to see if they had any threat of infecting humans, but that was disbanded by the current administration here in the United States. When science gets politicised, lives get lost.
Q: How do viruses spread so quickly?
[Professor Harish Nair]: Different viruses have different properties; you have some that are highly infectious and can spread easily from person to person, you can see that from their ‘r0’ (reproductive number). For example, the Measles virus has a reproductive number of 9 or 10, and can spread very easily; viruses with a lower number like avian influenza are less able to spread from person to person. It’s all down to how well viruses evolve, and their innate ability to propogate from one person to the other.
Q: Why are viruses so hard to fight?
[Professor John Oxford]: When Alexander Fleming discovered penicillin he was fairly lucky; it was a fairly-easy job to discover an inhibitor of bacterium compared to viruses. Bacteria are free living entities, you’ve got nothing else to mess-with! You get your molecule (in this case, penicillin) and target it towards this free-living bacterium- it either goes for it or doesn’t.
With a virus like COVID-19 or with influenza, they are parasites that use human cells- they only exist from the outside to transfer themselves, to replicate they have to be inside a cell. If you are developing an anti-viral drug, firstly it has to penetrate the cell- then it has to mess-around with the virus without damaging the cell components, it’s a huge effort.
Over the years, we’ve developed a plethora of antibiotics but only a handful of antivirals. We now have good antivirals against influenza, hepatitis C, B, HIV and smallpox and interestingly- some of those drugs are now being repurposed for COVID-19. Drugs like Remdesivir are showing promise against COVID-19.
Q: What can we learn from war-zone medicine for the COVID-19 pandemic?
[Dr. Zaher Sahloul]: Many of my colleagues are doctors who are part of the Syrian diaspora, and we have been dealing with endless crises over the past 9 years. We have experienced over 300 chemical attacks on hospitals according to some reports- and there are areas under siege that have millions of people, and a shortage of healthcare. Doctors have had to adapt to the siege, and treat people with limited resources – these same techniques are now being applied in our fight against the coronavirus- principles of planning, preparing, conserving and substituting of medication and supplies. We are having to reuse PPE and reallocate resources. This is exactly what we had to do in Syria.
I remember one of our physicians, he was performing surgery in his hospital north of Hamas. The hospital was hit with chlorine gas – he carried on with the surgery, and did not have the proper PPE. By the time he felt symptoms and was transported to a hospital that had a ventilator, it was too late – he died of cardiac arrest. Of course; the thing that happened in Syria that is not happening in the USA are the attacks on healthcare providers and hospitals- so far, almost 1,000 doctors and nurses have been killed in Syria.
For decades, we have been screaming for the international community to provide PPE to doctors on the front-line in Syria, and we are now doing the same here.
Q: Why are there so many conspiracy theories around COVID-19?
[Vincent Racaniello]: You see conspiracies every-time we have a virus outbreak, during the last major Ebola outbreak in West Africa- people said it was an American made virus, and that the military created it… People get comfort in understanding where things come from- so they turn to conspiracy when there’s nothing else. The internet has made conspiracies a great deal worse; it’s horrible.
Q: Could COVID-19 be a bioweapon?
[Vincent Racaniello]: Way back in January, the genome sequence of the virus was done. It was done immediately in China, and published- it was immediately clear that this [Covid-19] is a bat-virus, there’s no doubt. If you want to sit down with me, and we had the sequence in front of us, I could show you why it’s a bat virus. No human could have thought of putting the changes in the virus that made it affect human, nobody. I’ve been working in virology for 40 years, and so I can immediately see this is a bat-virus, but I can fully understand why this could be confusing. This is a new virus, it has a mechanism to infect people that nobody knew about before. This is a product of mother-nature, not human hand.
Q: Is there a link between 5G radio signals and COVID-19?
[Vincent Racaniello]: It is crazy to think there’s a link between COVID-19 and 5G, there is no science behind that whatsoever. The virus emerged from a bat, in a cave, 1,000 miles from Wuhan where there are no radio signals anyway. People all over the world are using 5G devices every-day, there is no correlation between 5G and coronaviruses.
Q: Could COVID-19 have been accidentally or deliberately leaked?
[Vincent Racaniello]: If you look at the genome of SARS-COV-2, it’s 96% identical to a bat virus we found in that cave, 1,000 miles from Wuhan in 2013. Nobody had that virus in their laboratory. When the scientists in Wuhan discovered this similarity, they only had a small piece of the virus sequence- so they had to go back to the cave, get some more samples, and sequence the virus. This virus is only 4% different from the last one we discovered. 4 bases out of every 100… and this thing is only 30,000 bases long, and only changes around 20 bases a year. So no, this is absolutely impossible- not happening.
Q: Could this virus have existed for a long time, with a vaccine/
[Vincent Racaniello]: We have known about coronaviruses since the 1960s, but they weren’t well known in the general public. As for the current pandemic, this is a brand new virus, only discovered in December/January last year- in all honesty, we should have a vaccine ready, we could have had one by now… we could have had antivirals, but the drugs companies said, ‘nah, there’s no market for it…’ and so nobody pursued it, and now we’re stuck.
Q: Can heat (saunas and hot drinks) kill the virus?
[Vincent Racaniello]: If I gave you a tube of the virus, you could apply a relatively high temperature for an hour, and it would inactivate the infectivity; but you can’t bring a person to that temperature, it would kill them. So, there is some truth that heating will inactivate a virus, but you can’t do that within a living body.
Q: Why do COVID patients require ventilation?
[Matt Strauss]: For everything else in medicine, we have textbooks. COVID is brand new, it’s a work in progress… We believe that COVID causes Acute Respiratory Distress Syndrome (ARDS), which means your lungs fill-up with fluid. If you twist your ankle, it becomes inflamed, filled with fluid and swells. With COVID, your lungs fill up with fluid- it’s like drowning on dry land and patients end-up very short of breath and may need ventilation support.
By the time you would require ventilation however, you would already be feeling pretty rotten. We wouldn’t consider putting someone on a ventilator until they require a high fraction of inspired oxygen (between 50 and 100%). If you’re at home, not on supplemental oxygen, and if you’re not short of breath when sitting, it’s unlikely you will need ventilation – but as always, you should seek medical advice.
I may be more open at saying this than most; but I feel that those in my field have been putting a high proportion of patients on ventilators who probably shouldn’t have been on them. Hope springs eternal, but a lot of the people we ventilate are hopeless cases.
I was thinking about the history of medicine, ventilators and resuscitation and life support, it brought to mind that in the 1700s when somebody drowned in the Thames, the current medical opinion was to blow tobacco smoke up their backside. And the royal humane society went so far as to put these pipes and bellows all along the Thames so that physicians could do this. In reality, the outcomes for those who drowned in the Thames was very dire, but at least it made the medical field feel better about what they were able to do.
Q: How does ventilation work?
[Matt Strauss]: When hospital doctors say, ‘we’re going to put you on a ventilator’ they usually mean invasive ventilation where they put you to sleep, put a plastic breathing-tube down your windpipe, into your trachea, and then connect that tube to a machine (the ventilator). That whole process is mechanical ventilation. You don’t even need a machine, it could just be a bag and air-bellows- but machines also have high-tech sensors that can give very precise amounts of pressure, and can sense and trigger cycles of respiration. If you basically think of it as hooking yourself up to bellows that are going to blow air into your lungs. That’s the physics.
We have to put you to sleep so that we can get the tube into your windpipe as quickly and safely as possible; and so it’s helpful if you’re motionless and can’t feel it. When you’re getting better and you need some ventilation but not full ventilation, you will probably wake-up with the tube in your mouth, with the machine pushing air into you. In many cases, you will probably also have your hands tied down. It can be a gruesome experience, but the trade-off is worse.
When you’re sedated (sometimes chemically paralysed) your muscles become weaker and can lose around 30% of their strength every 3 days. It’s one thing to not go to the gym for a few weeks, but quite another to be absolutely motionless in bed for a week. Things like blood-clots (as you may form in your legs from immobility on a flight) can be significantly worse. We also have to think about how we feed you. Another major problem is that you naturally have your vocal chords creating a separation between your lower respiratory tract and the microbes that are in the atmosphere and also in your mouth. When we’ve broken that barrier with our plastic tube, anything that seeps down the sides is liable to cause pneumonia.
Human lungs were not designed to receive positive pressure. When we breathe, we suck air like a vacuum cleaner. Todays’ ventilators push air into your lungs, sometimes at very high pressure, and if your lungs are very diseased the pressure can cause problems such as ventilator induced lung injury.
Q: Why has there been so much xenophobia and anti-China sentiment around Covid-19?
[Yonden Lhatoo] Oh that’s just the world’s default mode, especially in the West. Chinese immigrants have been easy targets for racial discrimination, victimisation and bullying since time immemorial and all this virus has done is bring more of it out into the open in all its ugly glory.
It borders on the bizarre when in India, Asian-featured northeasterners who have been “Indian” for generations are now targeted as “Chinese” coronavirus carriers by their own countrymen, and it hints at the ridiculous when Trump himself still talks about Asian-Americans as “they” instead of “us”.
So nothing new to see here, folks. Move along.
Q: What is the view from China on how the UK, Europe and USA have handled this pandemic?
[Yonden Lhatoo] There was a lot of talk that the initial mishandling of the outbreak and the way it snowballed into a pandemic would be the downfall of the Chinese Communist Party, but the successes it is now trumpeting would suggest the opposite. China may have given this virus to the rest of the world, but it is now trying to stop the rest of the world from returning the favour. It is watching the US, UK and Europe first doing it all wrong and now struggling to get it right. The Chinese people see it as incompetence on display by other governments to compare with the performance of their own.
Q: Did society not learn from the Spanish Flu?
[Professor John Oxford]: The 1918 pandemic was huge. I’ve spent a lot of my life working on it, I’ve even exhumed people who died in 1918 to get virus RNA from them. When trying to understand where the virus came from, how it did what it did, and where it went to, we end-up grappling with death-toll. Estimates of the number of deaths range from 40-100 million. In some ways, this virus was so big that we’ve all decided that something else must have happened- a unique set of circumstances in 1918. As the war was ending, we know there were 8-9 million soldiers battling on the Western Front – at this time, this virus emerged and then as the war ended, the soldiers went home and carried it with them. There were some very special circumstances, and that perhaps overtakes people’s view of why this pandemic occurred. In today’s world, more people move around in one day as they did in the whole year in 1918, so what was ‘special’ about transmission then, is ‘normal’ now.
Today’s world has pandemic plans- just take the 2000 outbreak of ‘bird-flu’ it triggered everyone’s responses- this new virus infected maybe 12 people in Hong Kong, half of whom died – it had a very high mortality rate, and focused the world. Shortly after there was the H5N1 influenza outbreak in South East Asian, and then the SARS outbreak. The first coronavirus arrived in 2003, then the MERS-Coronavirus a few years later.
We’ve underestimated the power of viruses like these. SARS started-up, infected 8000 people, and died-out with a lot of effort, public-health intervention and pressure. MERS hasn’t died-away, but was a fairly small outbreak, and now we have this. We’re going to have to learn to develop some vaccines and anti-viral drugs, these outbreaks will continue to happen again, and again, we have to get ourselves sorted.
This virus is not a clock, it’s a surviving creature, it wants to move, it wants to go from person to person- that’s what it wants. It couldn’t care less whether you have containment, it just wants to move- and by getting too close to each other, the virus proliferates. If we had engaged in these basic things back when we first heard about Covid-19, it would have saved us a lot of bother, perhaps we could have even knocked the virus on its head.
In 1918, that’s exactly what they dd in some cities in the United States. Some cities like New York and San Francisco introduced masks (home made!), disinfection, social distancing, school closures, banned public gatherings…. They did it in a layered way and they flattened out the curve and were able to deal with the pandemic more efficiently.
The biggest lesson from 1918 is this. We cannot hang around, we cannot wait for mathematical models to advise us, this is common sense, if a virus emerges, you have to stop it immediately.
Q: What are the comparisons between SARS-CoV-2, Coronavirus (COVID-19) and ‘flu’?
[Professor Harish Nair]: There’s a general statement people make when they have a respiratory virus; that they have ‘the flu’ – in reality, people could have any number of viruses; for example, in the elderly you may have an RSV (respiratory syncytial virus) and that would also resemble influenza…. The patient would have difficulty breathing, would have fever, would feel weak…
Most people also think flu is mild. It’s true that in the vast majority of people it could be mild, but in older people and those with pre-existing conditions (such as diabetes, heart disease, chronic obstructive lung disease) it can be lethal. Flu is a severe disease, but the fatality rate is around 1.2-1.3% in those who get hospitalised, and around 0.1-0.2% in the rest of the population. Flu viruses do mutate, and so you may not always have immunity- but there is some cross-protection offered from previous infections.
Coronavirus is completely new; it’s a zoonotic disease- it jumped to humans from animals- and is hugely infective, and so can spread easily from person to person. In terms of fatalities, it’s not in the realm of H7N9 (avian influenza) which kills 50% of those who get it, but it is still killing around 1-2% of those who get it; but at the moment, we don’t really know the true case fatality rate as the fatality rate depends on the setting and context. In Wuhan, the peak of the epidemic had a higher case fatality rate than China overall, and in Italy the fatality rate is high due to the numbers of elderly who have been infected. When the epidemic is over we will be able to understand what the true rates are- but it is certainly higher than influenza.
The human population has never been exposed to this virus so we are all potentially capable of getting infected, and some of us will get really severe disease.
Q: How did China bring the pandemic under control?
[Yonden Lhatoo] Using a combination of total state authority to enforce quarantine and other rules on a largely compliant population, backed by mass surveillance technology that allowed them to keep track of offenders and trace contacts of Covid-19 cases so they could contain the spread.
Shutting down entire cities, keeping tens of millions confined in their homes, conducting mass diagnostic testing to identify and isolate.
Whatever you may say about China, when it wants to get things done it gets things done, whether it’s building a massive hospital in 10 days or mobilising an entire nation to fight what it successfully portrayed as a common enemy to be faced by a united population – propaganda, yes, but highly effective in the fight against the disease.
Q: What are your views on the global response to SARS-CoV2 (Coronavirus)?
[Professor John Oxford]: China have been exemplary in their reaction to COVID-19. There has been a general lack of acknowledgement of this, too many ‘cold-war warriors’ who carry political baggage with them. The fact of the matter is this – China has risked the country, economy, and the lives of nurses and doctors to get this infection under control, not just for themselves, but for us too. Today, there are almost no new cases being picked-up in China. The only new ones are being imported from Europe to China. Unfortunately, I don’t see many of our politicians learning from the China experience; the Italians have done, but America is reluctant because of the policies of their President. You see exemplary publications on coronaviruses from China- they’re publishing in the highest journals of medicine – it’s high science, high quality, and a huge endeavour. We simply don’t have the economics and willpower to match their scientific capabilities- but we have to do our best. It’s important to be realistic though about how far we lag behind.
In the UK, people assume that the Italians are disorganised, for example, but they’ve got a very sophisticated medical set-up in Northern Italy with better hospitals than the UK.
We cannot accept our politicians in the UK praising the NHS when they have stripped it bare, driven away the European Doctors and Nurses we desperately need right now… Their solution? ‘oh, let’s bring the old-age pensioners back…’ – it’s preposterous, and makes me feel ashamed.
[Professor Christian Bréchot]: Let’s start at the beginning. China, for whatever political reason, did not report the epidemic. We have all heard the story of crackdowns of Doctors who gave early warnings. The second part of this story is that China has done exactly what it needed to- a complete lockdown. The Italians have started to do this, but it’s too late… The French have started to do this, but it’s too late… and the UK’s approach is just weird; for so many weeks- the UK was adamant the virus would not have the same impact as elsewhere but today they have to recognise it is coming.
Countries have- on an individual basis- generally reacted well, but what we’re lacking is global, coordinated action. I know it may feel idealistic but we have to get to the stage where if we see a virus emerging, instead of each country doing its own thing, we can have global coordinated action.
[Professor Harish Nair]: Everyone thought the next great pandemic was going to be influenza; we had a warning with avian flu. That being said, we did have a warnings of a SARS-like epidemic, but we thought it was possible to contain.
When a new virus emerges, it’s very difficult to ramp-up discovery and production of testing. For influenza, we develop test kits constantly- but for a new virus? It takes time, and can catch people off-guard.
We have to have basic measures in place, such as command and control strategies to effectively communicate with people, put social-distancing in place, close schools, close workplaces, suspend events, suspend sports fixtures…. None of that seems to have happened in this case. It was around the third week in January when the epidemic hit its peak win Wuhan, there were clear signs at that stage it was going to spread, and could not be contained in China. We’re not talking about some remote island here- there was local and international travel, and it was likely only a matter of days therefore before the virus reached every other part of the world.
Countries were not prepared, they were not willing to say ‘look, we will start testing in the community’. The main thing should be the identification of community transmission as soon as it started, which is what the WHO are saying. If you test more, you would be able to identify community transmission and then you can immediately put in place measures before you’ve got little pockets and little patches of transmission ongoing, and it starts to spread out.
[Professor Michael Osterholm]: Once a virus takes-on the characteristic of influenza virus like transmission, it’s like trying to stop the wind, you just can’t do it. People just assumed they could stop it- but that simply isn’t the case.
The measures being put in place may slow the virus down, but these are not sustainable measures. China has been in lock-down for 3 months, but once that lockdown is released- we will clearly see a resurgence of virus in China. The virus is not done there yet!
Reports have shown clearly that when you release these major suppression activities, you will see the curve come right back. The big driver is susceptible people in a population, and at this stage, the whole world is susceptible- and transmission will continue until either everyone has been infected, and we now have immunity- or we have a vaccine.
[Matt Strauss]: We are close to blindfolded in terms of how much information we have about this new beast. The only justification for this lockdown is to flatten the curve- but ultimately the same number of people are going to get this virus unless we devise some amazing new treatment or a vaccine. Treatments take a long time to develop (we still don’t have one for flu), but a vaccine could take 18 months to 2 years.
The damage to the economy will be huge. It will be so hard for people to keep body and soul together without doing any work for a long period, it’s just not feasible. If we social-distance for 6 months, then we relax the isolation, we’re going to have the same peak that we put off for 6 months, so there’s a degree of futility in our approach.
Q: Do you think the world’s reaction to Coronavirus is a warning of how we would react to a much worse virus?
[Professor Christian Bréchot]: The Corona virus we are facing is a SARS virus, it has the name SARS-CoV2. We had SARS-COV1 in 2003, we then had MERS-CoV and now SARS-CoV-2. We still do not know the true mortality rate of the SARS-CoV-2, the present epidemic. We will have many more cases which will be discovered and identified, and it is likely that the mortality rate will be much lower than what has been announced. However, we cannot fix our ideas on this. Now we have an estimate of 0.5-0.8% mortality for young people, which rises to 2-3% for people who are between 60-80 or who have pre-existing condition, and then which rises to 6-12% for those above 80 years old. These are estimates… but in anycase, it is at least 5-10x more deadly than typical flu which has a mortality rate of 0.1%, meaning that in young people the mortality rate is more-like 0.05% – This is nowhere near the severity of SARS-CoV-1 or MERS-CoV which had mortality rates of 10-15% and 30% respectively. What is equally important as mortality, is contagiosity. SARS-CoV-2 is 3-5x more contagious than flu.
We have to first acknowledge that there are many things we don’t know; we have to put measures in place, and brace for the worst case scenario- and if that doesn’t manifest, that’s great news. Second, when we think of mortality rate, we have to think of contagiousness too- otherwise it makes no sense.
We also have to think of the context. In Italy, they have had a mortality rate of 3-3.5%, most of these people are older, and the virus has hit nursing homes and older communities hard.
We have to also be very careful of narratives that are developing, some people have said, ‘OK, but these are people who would have died a few months later anyway, they were so old and infirm…’ but we cannot buy into these narratives, it means we are condemning an entire generation of people.
Q: What are your views on the media response to coronavirus?
[Gideon Lichfield]: Our media response to coronavirus has been a function of the information ecosystem we have built over the past few decades. Today’s media require stories to spread over social media for the business model to be ‘successful’ and social-media platforms require people to engage, read, and spend a lot of time on the platform for their business model to be successful. Politicians also feel they’re required to respond immediately to everything that’s in the news cycle- and news cycles keep accelerating.
The media does a good job of reporting, but it’s the nature of the way information is consumed and circulated that we overdose on it. We overdose on information, and yes- there is some good stuff- but it’s stress inducing and it can be very hard for a person who is just reading this flood of information to form a coherent picture of it, unless it’s their job to do that.
Q: What is ‘the curve’ of a virus, and how can we get it down?
[Professor Harish Nair]: The ‘curve’ is the ‘epi-curve’ (epidemiological curve)of the r0 and in any outbreak situation, you can use this to find out how quickly the outbreak is spreading from person to person, and can help you learn whether it’s a common source or propagated source epidemic. A common source epidemic is something like a single hand-pump in a village that’s causing a cholera outbreak; whereas a propagated source epidemic is where a person gets infected, and becomes a source of transmission to another person. One person could (for example) spread the infection to 3 people, who in turn could infect 3 more people, giving an r0 of 3. In this example, an outbreak can spread rapidly- but once you have exhausted the number of susceptible people, the curve starts to drop and the epidemic will end.
Now; what you could do is either put in place measures to delay the epidemic- prophylactic measures such as hand-washing, personal prophylactic equipment (PPE gear)…. You will not reduce the number of people who are susceptible, but you will reduce exposure of those susceptible and are trying to decrease the burden on the healthcare system such that you don’t have a lot of very sick people turning up to your hospitals and clogging up your ICUs.
For example; if 100 people were to arrive over a 4 day period, you may not be able to deal with it due to limited bed availability- but if they spread over 40 days? You could possibly deal with that.
Flattening the curve using social-distancing and prophylactic measures is the only method we have available to us until we can find a vaccine and immunise people, reducing the number of susceptibles.
Q: What can we as individuals and communities do during viral outbreaks and pandemics?
[Professor John Oxford]: Every single one of us can play a role during outbreaks and pandemics, and we have to. When we come out of this our grandchildren may say to us, ‘Grandad… what did you do during the great COVID?’ – imagine saying you did nothing – how awful would that be! We need to be saying, ‘I restricted my travel, I didn’t go on holiday that year, I didn’t go to the meetings and conferences… I cancelled this, I cancelled that… I washed my hands 10 times a day…. I didn’t kiss and hug people… I didn’t get too close to people… I made sure I didn’t get close enough to breathe anyone else’s air…’ We can all do these small things.
When it comes to masks though… I don’t think they do a great deal… we have to focus on handwashing, social distancing, those measures. If after everything we are still not making progress? Then, I guess there’s no harm putting on a mask – but even then, it has to be the right type; the people who are just wearing paper masks don’t seem to realise they do nothing.
[Professor Christian Bréchot]: There is only one way to prevent epidemics, and that is to have good vaccines. In terms of managing epidemics, we have to firstly have diagnostics in-place, and then we have to create the cultural norms that mean that people respect the need to not shake hands, to not give hugs, to stay the appropriate distance away from each-other. This is a social responsibility we have for each other.
When young people get coronavirus, they may not even notice; but they are able to transmit to an older person, or somebody with a pre-existing condition, immuno-suppression and that might kill that person.
It’s shocking that some countries have been so slow to take measures. If France and the United Kingdom had done the right thing, they would be handling this smoothly- but instead- they were looking at Italy saying, ‘oh no, it’s so sad what’s happening there…’ without realising the same was happening on their own doorstep. We are now in the exponential phase and nobody in the world is safe from this pandemic.
[Dr. Roberto Consentini]: The key factor is social-distancing, this is the only way to decrease the spread of the covid infection. From the perspective of hospitals? They have to reorganise, and prepare to admit a lot of patients with severe pneumonia. We have never seen anything like this before. I have worked in emergency medicine since 1991, and I’ve never seen pneumonia like this before.
Q: What are your views on the concept of ‘herd immunity’?
[Professor John Oxford]: The currently proposed idea of herd immunity is getting awfully close to social eugenics. There have been people, quite senior in their field, sying things like ‘if we just let this virus rip through, maybe it will clear out the wards with elderly people blocking our beds…’ – That kind of commentary is dangerous, shocking, and we cannot allow it.
Q: How can politicians communicate about epidemics without causing panic?
[Professor Christian Bréchot]: Politicians face an extremely difficult situation, but they must be humble and work with facts and experts. It is easy for politicians to be accused of being alarmist but they have a job to do; and that means they have to take a serious stance. What I do not agree with is what has happened in the UK or USA where the situation was downplayed, and then they had to u-turn, this causes a breakdown of trust. You have to be consistent, you have to explain that this is a big deal.
I believe that it makes sense that the politicians take from the very beginning a very serious case, and yes in certain situations on a retrospective basis they will be accused of having been too much alarmist. But I believe that that’s their task.
Q: Do we have promising treatments for novel and emerging viruses?
[Professor John Oxford]: Covid-19 is not a human virus, it came- most probably- from a bat, and just like other viruses such as Ebola and Zika, people immediately go, ‘make a vaccine!’ – we have to remember that vaccines are tricky beasts, they may or may not work, and if done wrong? They can make things worse, and have done in the past. You need vast industries, with a lot of experience. People are saying we may have a vaccine in 4 months, but we have to take that with a pinch of salt; we’re talking about vaccinating the whole world here. The biggest and most capable pharmaceutical companies are now in China, they dwarf GSK and Merck and have unbelievable scientific prowess- it’s like nothing you’ve ever seen. If I was looking towards who will make a vaccine, I would look to China, and possibly Russia, not Oxford – and realistically it will take at least a year to get anything safe.
What is also promising is the world of anti-virals. Wouldn’t it be great to have a packet of anti-virals with you, so that if you came into contact with someone ill, and they sneezed on you, you could just take these post-exposure prophylaxes. There are drugs which have been developed to treat other viruses such as Ebola which could potentially be repurposed to fight coronaviruses, they have been through clinical trials, are known and scientists are working with them as we speak. The Rega Institute for Medical Research in Leuven, Belgium has packaged up 50,000 molecules from other viruses and are screening anti-viral drugs to see what could be effective. I think it’s likely we’ll see anti-virals before a vaccine.
[Professor Christian Bréchot]: In a decade, we will have lots of PhD’s and studies of this situation, but I hope this pandemic is a trigger for a global coordinated approach to begin. Governments have to share the same attitudes and strategies; and that’s going to be extremely difficult. SARS-CoV-1 was the first warning call in 2003, and SARS-CoV-2 Is a second warning call, but it still caught us by surprise.
Organisations like the Coalition for Epidemic Preparedness Innovations (CEPI) are financing and coordinating the development of vaccines against emerging infectious diseases, and the aim is to get us prepared. We need a coalition on drug discovery and drug repurposing. New therapies take years to develop, but there are existing therapies that could be repurposed for novel viruses.
I also believe we will see much greater coordination between government, private and research sectors through organisations like the Global Virus Network which will help the world be better prepared for future outbreaks.
Q: How has China been assisting the rest of the world during this outbreak?
[Yonden Lhatoo] China is, after all, the world’s biggest producer of basic medical supplies, so it has been sending tonnes of that to Europe – millions of masks and testing kits, in particular, which are desperately needed there.
It has also been sending medical teams, fresh veterans of fighting the contagion in their own country, to help other nations with their new experience.
Q: Do you think Covid-19 will change the role of China on the world stage?
[Yonden Lhatoo] Well, that’s probably something China has already been contemplating, as evidenced by President Xi Jinping’s recent flurry of phone calls to the leaders of France, Germany, Spain and Serbia, offering Beijing’s full support for their battle against the coronavirus.
Quite an intense diplomatic gesture, but is it an indication that it already has a post-coronavirus world order in mind? Or we’re getting ahead of ourselves, because this global public health crisis is far from near any end.
Q: What are your thoughts on the shift of primary care to video consultations following this pandemic?
[Professor Trish Greenhalgh]: Everett Rodgers originated the theory of innovation diffusion. He lived in a place called Iowa in America, a big oblong state- right in the middle of the USA. All they do there is grow corn and when I was a youngster, I hitch-hiked across it – it took me a whole day to get across the state- it’s huge. The state comprises of huge farms, very isolated from each-other and that’s where Everett Rodgers did his work on the diffusion of innovation. He interviewed all these farmers asking why they weren’t taking-up new farming practices that had been developed after the war (intensive farming, fertilisers, and so on) that would help prevent starvation. He did some meticulous research and identified that more than anything else the thing that would determine whether or not an innovation was taken up was relative advantage.
Now, in a healthcare setting- even a couple of months ago- doctors were saying, ‘well, we don’t need to use video consultations, patients can come to us in the surgery… phone us up for home visits…’ – this was standard practice for most doctors. Suddenly, COVID emerges – it’s may-more times more contagious than flu, and many times more serious. This combination of contagiousness and seriousness means that video-consultations have a massive relative advantage.
I have recently spoken with a colleague who has a receptionist on intensive care with COVID; that’s the reality doctors are dealing with now – not only might you, as a doctor, die – but your staff might do also.
I’ve got skin in the game, my son’s a junior doctor. We don’t want to have the patient in the room with us. And that means the relative advantage has flipped overnight from being almost zero for GPs in most situations to being overwhelmingly in favour.
Q: What will be the impact of COVID-19 on the global south?
[Dr. Zaher Sahloul]: If coronavirus gets a foothold in Syria, or other places with ongoing disasters, it will be catastrophic. The concept of social distancing is impossible in a camp where you have a large number of people. I was in Idlib a couple of months ago, and you have 1.2 million people living across 1,250 camps. Imagine, you have sometimes 15 people in a tent- how can they social distance? Even the basic things we recommend, hand-washing with soap and water… even that can be difficult in a refugee camp.
My hospital in Chicago has more mechanical ventilators than Syria and the Gaza Strip combined.
I hoe that we won’t see a spreading of the pandemic in Syria, Yemen or Gaza or places like that; it would be catastrophic.
I was with my team in Sierra Leone a couple of years ago, this is a country that lost over a third of all its healthcare workers due to Ebola, and now have a handful of ventilators for the whole 8 million population. We’re partnering with MIT to look at how mechanical ventilators can be made locally, cheaply and for mass respiratory care casualties.
Q: How can we protect the mental health of our primary care staff?
[Professor Trish Greenhalgh]: I recently read that 50% of healthcare workers on the front-line now meet the criteria for diagnosis of anxiety, depression, major stress disorder and post-traumatic stress disorder. 50%…. A lot of our medical professionals are also going to get sick themselves, this is scary.
I study complexity, and one of the things I’ve been very interested in is networks. Junior doctors, senior doctors and other professionals have their networks- and now we’re seeing community resilience networks emerging. This has to go wider- we have to think and collaborate globally, and also act locally.
For medical professionals; you also have to protect yourself, to stop yourself going nuts at a time like this. There is a constant stream of news, and at the front-line you are seeing it with your own-eyes- but it’s important to have structure. I have a very strict routine in the mornings including exercise, breakfast and some time being mindful. Structure gives you a sense of control.
You also have to realise that you can do what you can; but also need to keep talking to help make sense of things that are going on.
We’re going to be in this situation until there’s a vaccine; that I’m sure of – and we have to keep our doctors and health professionals resilient.
[Dr. Zaher Sahloul]: The physical and mental health of doctors is often ignored. Burnout syndrome is a well-known problem in critical care, and has been even before this pandemic. As a critical care doctor, you are making difficult decisions and dealing with life and death every day. In disasters like Syria, you see the extremes of this and have to be resilient. That is the key word- you have to think about how you can make sure your medical staff continue to be able to take-care fo very difficult cases, take decisions, and not undermine their mental health. In crises, you run on adrenaline – so you don’t often pay close attention to your own mental health, and this can some times last days. When the crisis is finally over? You can get PTSD, anxiety, depression and problems that impact your relationship, your spouse, your business and your family. We have to provide our healthcare workers with the tools for resilience.
In Syria, there was a major sarin gas attack in Ghouta in 2013. One of my classmates from medical school was an anesthesiologist in a city called Ein Tarma. His hospital received 700 patients who were choking- basically suffocating to death- with exposure to sarin gas. He had a few ventilators, and had to decide which patients to hook-up; and so he chose the youngest, the children, and any pregnant women. By the morning, he had lost 140 patents. Until now, he is haunted by the memories of what happened that night.
Q: What can we learn from past pandemics for today’s?
[Professor John Oxford]: One of the most inspiring aspects of 1918 was the honour and duty people felt. We’re seeing it today too- those doctors in China aren’t running away (they could if they wanted to…). They’re facing this virus, they’re dying in the process of saving lives, and it’s the same in Italy and I fear it will be the same in the UK and USA.
Looking back at the 1918 flu, most people died in their homes. I suspect that’s what the government is planning here too. I saw a cartoon in the Guardian last week which showed our Prime Minister saying, ‘…wash your hands, go home and die’ it was almost summarising what they seem to be planning… Locking the over-70s in their homes to die quietly….
Certainly in 1918, there was nowhere else to go- the hospitals were stripped bare as all our capacity was on the Western Front. Hospitals were used for wounded soldiers, so nobody had a choice but to stay at home. Most people died quietly, at home – I’ve seen many letters people wrote to each other days before they died. They weren’t panicked, they did their best.
Q: What are your views on masks for personal protection?
[Trish Greenhalgh]: The level of PPE that has been provided to healthcare workers as of right now is woefully inadequate. We’re not talking about fancy respirator masks here, but even gowns with sleeves and basic disposables. They’re rationing masks and only using them if someone is actively coughing – even though we know that patients without symptoms can transmit COVID. Primary care workers should be wearing masks, all the time, for all patients – and we simply don’t have enough. This is an urgent situation.
Q: Are we doing enough to protect our medical staff?
[Matt Strauss]: I’m not terribly concerned about getting COVID myself, I’m 34- relatively fit- and don’t have any underlying medical problems. If you’re over 50, asthmatic, a smoker or have other underlying conditions then yes, this is a pretty scary disease.
I’ve been emailing colleagues who I know are over 50 and asking if they want me to take their shift to protect them; but the culture of those medics is that they’re not going to stay home and sit this out…. So it fell on deaf ears.
The other concern is the reports of healthy, young Chinese doctors in Wuhan who died. Whether it’s from repeat exposure or dose-response we don’t know. They were living, sleeping and eating in a hospital with very sick patients coughing all over them. COVID may be more successful therefore at killing folks with that degree of exposure.
We have to protect our workers to the highest degree possible and it does shock me that nobody thought to count the masks and gloves that they had in store…
Q: How long do viral pandemics last?
[Professor Harish Nair]: This is a new virus, we are all susceptible. As more people get infected, they will become immune- and that immunity may last anywhere from several months to several years. We will not have lifelong immunity, but we may have long term immunity, which may buy us enough time to create a vaccine.
The worst-case scenario is that this virus runs through the entire population of the world, and can no longer sustain transmission. It may therefore remain a circulating virus in the human population, but will not cause a lot of disease. In the short term; measures such as social distancing, cutting the transmission, may allow us to stop the immediate spread of the virus- containing the outbreak, and may allow life to return to normal; but we would have to be mindful of another outbreak. We’re living in a society where people travel, mix, and so the chance of outbreaks restarting is always there.
Most of these respiratory infections remain indistinguishable from each other without a test; and until a vaccine can be deployed, we will just have repeated cycles of outbreaks- and realistically? A vaccine may be at least 18 months away, and we may not be able to immunise more than a third of the world’s population, simply because we don’t have the capacity to make enough vaccines.
Where coronavirus is concerned however, nobody is an expert. We are all learning every day with new data that is coming through. There are some key lessons though. The world was woefully underprepared for this outbreak. The WHO have been asking countries to prepare pandemic influenza plans since 2002, a message reinforced after the 2009 pandemic, and most countries either don’t have a plan or that plan was never tested- so they simply have not responded. Some countries do annual-drills, but even they got caught out with the mindset of, ‘we don’t think we will have a problem…’ – this mindset only works until the problem gets so big that you can no longer contain it. Then you have this knee-jerk reaction of shutting everything down, causing panic.
Coronavirus is a moderate virus, it’s not something that will wipe out half the human population but we have to be prepared for just those kind of viruses. Any of these highly pathogenic avian influenza viruses- with mortality rates of 40-60%- could become transmissible from human to human, and we would not be able to do a thing. Life would come to a complete standstill.
We need to learn from this and adjust, and make sure we have adequate contingency plans in place for the future.
[Dr. Roberto Consentini]: I hope that countries will flatten the curve of infection spreading by doing the right things, and that will allow countries to prepare better and avoid the huge amount of patients with respiratory challenges; that is my word of hope for you. Here in Italy, we are experiencing the worst case scenario, and I hope the rest of the world will not.
Figures speak to the brain, but not the heart. When we read the papers published by Chinese doctors, we didn’t realise- until we saw it with our own eyes- how serious this virus was. As we saw the first cases coming into our hospital, we went to Lodi Province (the heart of the outbreak in Italy) and we saw a massive amount of cases- hospitals were full of patients in acute respiratory failure and distress; it was a warning sign to us, of what was to come.
[Professor Michael Osterholm]: As this point, we have three options. Firstly, we can suppress transmission as much as we can- particularly among those who are most at risk. Secondly, we can suppress activity in such a way that the population are able to carry on their lives, but we protect those most vulnerable. Thirdly, we can keep suppression on the whole population- that simply cannot work. If you ring a bell to put these measures in place, how do you un-ring it? Nobody has had to figure that out. We’ve gone from 0-100mph. Two weeks ago, this wasn’t a problem for politicians- and today, we’re on a war-footing.
This pandemic will make us review everything; just look at supply chains. Right now, so much of our critical medical supply chain is concentrated in China, this may be efficient economically, but it poses huge resilience risks.
We’ll never go back to normal, ever. We’ll go back to a new normal. As much as air transportation changed after 9/11, so will our world relative to what a pandemic can do- I have no doubt about that.
Q: Will life ever return to ‘normal’?
[Gideon Lichfield]: Studies and models have shown that to bring the pandemic under control we will need a solid 18 months of social-distancing to buy-time for the discovery and production of a vaccine. We may obviously find a cure, or treatment, sooner – and we may also find-out that the virus is far more widespread than we thought, meaning that the social-distancing measures are redundant. Until we start testing the population, we simply will not know what level of immunity exists.
Barring those exceptions; it’s clear that social-distancing will have to remain in-place for extended periods of time until we get a vaccine. The economic effect of this is just unimaginable; we will rebound, but it will take time. We also need to adopt a very different kind of readiness to make sure this doesn’t happen again- and that means having a mixture of healthcare and infrastructure so that we can quickly look for treatments and vaccines for diseases- it also, honestly, means we need the kind of surveillance infrastructure that allows us to track people who have suspected cases, track their contacts, and monitor them in the way we’ve seen in Singapore and a few other places in Asia. We will also have to rethink our social norms around contact; recognising that our society simply isn’t resilient enough to deal with shocks like this.
There will always be silver linings too. On one hand, there are always people who profit from disasters- but on the other, there will be better ways to do business, more sustainable ways to work, and a society which- through culture and policy- has new ways of behaving, perhaps through a conscious awareness of our vulnerability. We are rediscovering the meaning of connection with people- and learning how to have meaningful connections at a distance.
[Vincent Racaniello]: Distancing isn’t being done by everyone, and that’s a problem. There are still huge parts of the US where people are going about their lives as normal, and that’s perpetuating infection. In the end, we’re not going to be relying entirely on social distancing, we’re going to have to let the virus take its course. I think there are way more infections than we know about because we’re hardly testing. I suspect the numbers will be tenfold to twentyfold more than officials are saying, and that will immunise a good fraction of the population towards the summer, but I suspect the virus will come-back in the winter months and quite a few people who weren’t infected first time round will probably get infected- but this outbreak will probably be smaller than this current pandemic, and so we will hopefully not have to shut down the world.
Q: What would be your advice to doctors at the front-line?
[Professor Trish Greenhalgh]: You have to contain the pressure you put on yourself. You have to draw a box around yourself and say, ‘this is what I’m going to be worried about, this is what I’m going to take responsibility for…’ and realise there’s a certain amount you can do, but the rest is largely out of your control.
For example; in my own life, I have been getting lots of emails about ventilators- and whilst they are certainly important and interesting I have to say, ‘I haven’t got the headspace for ventilators right now, I’m focussing on primary healthcare and video consultations… that’s it.’
Also, and this is important, make sure you never forget that family comes first.
[bios]John Oxford is the UK’s top expert on influenza and Emeritus Professor of Virology at the University of London. His work on the 1918 strain of influenza (Spanish flu) is world famous.
Professor Oxford is the founder of Retroscreen Virology, a leader in the field of vaccine and anti-viral clinical trials for the last 20 years. He is also co-author of Human Virology, now in its 4th Edition and published by Oxford University Press.
Professor Oxford appears regularly on Radio 4’s Today programme, BBC’s Newsnight and ITV and Channel 4 News talking about influenza and, more recently, Ebola.
Christian Bréchot holds MD and PhD degrees. Beginning in 1981 he studied molecular biology, virology, and cellular biology at the laboratory of Pierre Tiollais at the Pasteur Institute, and at the Necker school of medecine (Paris Descartes University); he obtained his PhD in biochemistry from the University of Paris VII in 1985.
In 1989, he became full professor of Cell Biology and Hepatology,at Paris Descartes University and in 1997 he was appointed head of the clinical department of liver diseases at the Necker-Enfants Malades Hospital. He was head of a research unit at the Necker Faculty of Medicine, jointly supported by Inserm, Paris Descartes University, and the Pasteur Institute; he was also head of the National Reference Centre on viral hepatitis from 1998 to 2001.
From 2001 to 2007, Christian Bréchot was General Director of Inserm, the French National Agency for biomedical research. In 2008, he was appointed as Vice-President of Medical and Scientific Affairs of the Institut Merieux company, where he merged the efforts of four sectors including in vitro diagnostics, preventive vaccines, therapeutic vaccines, as well as food safety (Biomérieux, Transgene, Merieux Nutrisciences, Advanced Bioscience Laboratory). From October 2013- September 2017, Dr. Bréchot served as President of the Institut Pasteur developing programs to recruit eminent scientists, implementing an international multidisciplinary education and teaching program, fostering collaborative research and training strategies with major universities and research organizations, coalescing the international network of 33 Pasteur Institutes to encompass a global scientific vision and coordinated training activities, and positioning an ambitious and internationally oriented strategy for technology transfer and fundraising.
He is currently a full Professor with tenure at the University of South Florida in Tampa and Executive Director of the Romark LLC Institute for Medical Research, also based in Tampa. Since October 2017, he has served as President of the Global Virus Network.
Dr. Bréchot’s research activities have been focussed on viral hepatitis: hepatitis B (HBV) and C (HCV), particularly with regard to their role in liver cancer (Hepatocellular carcinoma: HCC) and to the molecular mechanisms that drive liver regeneration and cancer (in particular, cell cycle deregulation and the impact of oxydative stress). He has been the member of numerous scientific committees and societies and has received prestigious awards. Dr. Bréchot is the author of over 350 articles published in medical and scientific journals. In addition, his research activities have led him to obtain 13 patents and to contribute to the creation of three biotech companies : Rarecells, ALFACT Innovation and The Healthy Aging Company.
Trained in clinical Paediatrics and Epidemiology, Prof Harish Nair leads the Respiratory Viral Epidemiology research programme at the University of Edinburgh. He has led several large collaborative projects on global child health and infectious diseases. He currently leads (and is the co-ordinator of) the REspiratory Syncytial virus Consortium in EUrope (RESCEU) (www.resc-eu.org) and the RSV Global Epidemiology Network (RSV GEN). He is a co-founder of ReSViNET (www.resvinet.org).
Prof Nair is both medically and scientifically trained (MBBS from Maulana Azad Medical College, Delhi in India and PhD from University of Edinburgh). His research focuses on child pneumonia. He has received >£31M in grant funding from the Bill and Melinda Gates Foundation, European Commission, World Health Organisation, UNICEF and Sanofi Pasteur). He has led studies that reported the first and most widely cited disaese burden estimates for RSV and influenza related child pneumonia. Apart from his main interest in child pneumonia epidemiology, he has a strong interest in refugee health and gender inequities in child health and has contributed to internationaly leading resarch on neonatal health, maternal health and health sector reforms.
Dr. Roberto Consentini is Emergency Medicine Chief of the Papa Giovanni XXIII hospital in Bergamo.
Dr. Osterholm is Regents Professor, McKnight Presidential Endowed Chair in Public Health, the director of the Center for Infectious Disease Research and Policy (CIDRAP), Distinguished Teaching Professor in the Division of Environmental Health Sciences, School of Public Health, a professor in the Technological Leadership Institute, College of Science and Engineering, and an adjunct professor in the Medical School, all at the University of Minnesota. From June 2018 through May 2019, he served as a Science Envoy for Health Security on behalf of the US Department of State. He is also on the Board of Regents at Luther College in Decorah, Iowa.
He is the author of the 2017 book, Deadliest Enemy: Our War Against Killer Germs, in which he not only details the most pressing infectious disease threats of our day but lays out a nine-point strategy on how to address them, with preventing a global flu pandemic at the top of the list.
In addition, Dr. Osterholm is a member of the National Academy of Medicine (NAM) and the Council of Foreign Relations. In June 2005 Dr. Osterholm was appointed by Michael Leavitt, Secretary of the Department of Health and Human Services (HHS), to the newly established National Science Advisory Board on Biosecurity. In July 2008, he was named to the University of Minnesota Academic Health Center’s Academy of Excellence in Health Research. In October 2008, he was appointed to the World Economic Forum Working Group on Pandemics.
From 2001 through early 2005, Dr. Osterholm, in addition to his role at CIDRAP, served as a Special Advisor to then–HHS Secretary Tommy G. Thompson on issues related to bioterrorism and public health preparedness. He was also appointed to the Secretary’s Advisory Council on Public Health Preparedness. On April 1, 2002, Dr. Osterholm was appointed by Thompson to be his representative on the interim management team to lead the Centers for Disease Control and Prevention (CDC). With the appointment of Dr. Julie Gerberding as director of the CDC on July 3, 2002, Dr. Osterholm was asked by Thompson to assist Dr. Gerberding on his behalf during the transition period. He filled that role through January 2003.
Previously, Dr. Osterholm served for 24 years (1975-1999) in various roles at the Minnesota Department of Health (MDH), the last 15 as state epidemiologist and chief of the Acute Disease Epidemiology Section. While at the MDH, Osterholm and his team were leaders in the area of infectious disease epidemiology. He has led numerous investigations of outbreaks of international importance, including foodborne diseases, the association of tampons and toxic shock syndrome (TSS), the transmission of hepatitis B in healthcare settings, and human immunodeficiency virus (HIV) infection in healthcare workers. In addition, his team conducted numerous studies regarding infectious diseases in child-care settings, vaccine-preventable diseases (particularly Haemophilus influenzae type b and hepatitis B), Lyme disease, and other emerging infections. They were also among the first to call attention to the changing epidemiology of foodborne diseases.
Dr. Osterholm was the Principal Investigator and Director of the NIH-supported Minnesota Center of Excellence for Influenza Research and Surveillance (2007-2014) and chaired the Executive Committee of the Centers of Excellence Influenza Research and Surveillance network.
Dr. Osterholm has been an international leader on the critical concern regarding our preparedness for an influenza pandemic. His invited papers in the journals Foreign Affairs, the New England Journal of Medicine, and Nature detail the threat of an influenza pandemic before the recent pandemic and the steps we must take to better prepare for such events. Dr. Osterholm has also been an international leader on the growing concern regarding the use of biological agents as catastrophic weapons targeting civilian populations. In that role, he served as a personal advisor to the late King Hussein of Jordan. Dr. Osterholm provides a comprehensive and pointed review of America’s current state of preparedness for a bioterrorism attack in his New York Times best-selling book, Living Terrors: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe.
The author of more than 315 papers and abstracts, including 21 book chapters, Dr. Osterholm is a frequently invited guest lecturer on the topic of epidemiology of infectious diseases. He serves on the editorial boards of nine journals, including Infection Control and Hospital Epidemiology and Microbial Drug Resistance: Mechanisms, Epidemiology and Disease, and he is a reviewer for 24 additional journals, including the New England Journal of Medicine, the Journal of the AmericanMedical Association, and Science. He is past president of the Council of State and Territorial Epidemiologists (CSTE) and has served on the CDC’s National Center for Infectious Diseases Board of Scientific Counselors from 1992 to 1997. Dr. Osterholm served on the IOM Forum on Microbial Threats from 1994 through 2011. He has served on the IOM Committee on Emerging Microbial Threats to Health in the 21st Century and the IOM Committee on Food Safety, Production to Consumption, and he was a reviewer for the IOM Report on Chemical and Biological Terrorism. As a member of the American Society for Microbiology (ASM), Dr. Osterholm has served on the Committee on Biomedical Research of the Public and Scientific Affairs Board, the Task Force on Biological Weapons, and the Task Force on Antibiotic Resistance. He is a frequent consultant to the World Health Organization (WHO), the National Institutes of Health (NIH), the Food and Drug Administration (FDA), the Department of Defense, and the CDC. He is a fellow of the American College of Epidemiology and the Infectious Diseases Society of America (IDSA).
Dr. Osterholm has received numerous honors for his work, including an honorary doctorate from Luther College; the Pump Handle Award, CSTE; the Charles C. Shepard Science Award, CDC; the Harvey W. Wiley Medal, FDA; the Squibb Award, IDSA; Distinguished University Teaching Professor, Environmental Health Sciences, School of Public Health, UMN; and the Wade Hampton Frost Leadership Award, American Public Health Association. He also has been the recipient of six major research awards from the NIH and the CDC.
Yonden Lhatoo is the Chief News Editor at the Post. He had worked as a television news anchor and editor in Hong Kong for nearly two decades before joining the SCMP in 2015.
Gideon Lichfield has been the editor in chief of MIT Technology Review since December 2017. He spent 16 years at the Economist, first as a science and technology writer and then in postings to Mexico City, Moscow, Jerusalem, and New York City. In 2012 he left to become one of the founding editors of Quartz, a news outlet dedicated to covering the future of the global economy that is now widely recognized as one of the most innovative companies in digital media. Gideon has taught journalism at New York University and been a fellow at Data & Society, a research institute devoted to studying the social impacts of new technology. He grew up in the UK and studied physics and the philosophy of science.
Yonden Lhatoo is the Chief News Editor at the Post. He had worked as a television news anchor and editor in Hong Kong for nearly two decades before joining the SCMP in 2015.
Trish Greenhalgh is an internationally recognised academic in primary health care and trained as a GP. She joined the Department in January 2015 after previously holding professorships at University College London and Queen Mary University of London.
As co-Director of the Interdisciplinary Research In Health Sciences (IRIHS) unit, Trish leads a programme of research at the interface between social sciences and medicine, with strong emphasis on the organisation and delivery of health services. Her research seeks to celebrate and retain the traditional and humanistic aspects of medicine while also embracing the unparalleled opportunities of contemporary science and technology to improve health outcomes and relieve suffering.
Trish is joint module coordinator on the Knowledge Into Action (KIA) module of the MSc in Evidence Based Health Care.
Her past research has covered the evaluation and improvement of clinical services at the primary-secondary care interface, particularly the use of narrative methods to illuminate the illness experience in ‘hard to reach’ groups; the challenges of implementing evidence-based practice (including the study of knowledge translation and research impact); the adoption and use of new technologies (including electronic patient records and assisted living technologies) by both clinicians and patients; and the application of philosophy to clinical practice.
Current research projects include
- Partnerships for Health, Wealth and Innovation – a ‘research-on-research’ study of the co-creation and implementation of innovations in the Oxford Biomedical Research Centre (NIHR funded);
- SCALS (Studies of Co-creating Assisted Living Solutions): A predominantly qualitative and developmental programme of research to improve how we design, introduce and evaluate technology-supported integrated care in older people with complex needs. This includes a new 4-year Senior Investigator Award from the Wellcome Trust;
- The NIHR-funded VOCAL study of the conversational dynamics in remote (‘Skype’) consultations;
- The NIHR-funded RAMESES-II study to develop methodological standards for realist evaluation.
Trish is a fellow at Green Templeton College. She is in principle keen to hear from prospective DPhil students in her areas of interest but currently has a full quota of doctoral students and a waiting list.
Trish is an active contributor to the social media site Twitter: @trishgreenhalgh
Trish has produced a video lecture on primary care here: Greenhalgh, T. (2018, June 27). The academic basis of primary health care [Video file]. In The Biomedical & Life Sciences Collection, Henry Stewart Talks. https://hstalks.com/bs/3780/.
Mohammed Zaher Sahloul is a Critical Care specialist serving patients in the Chicagoland area. He is also president of Pulmonary Consultants.
He is the cofounder and president of MedGlobal, a medical NGO, dedicated to reduce healthcare disparity by sending medical missions to disaster and underserved areas globally.
Between 2011 and 2015, Dr. Sahloul led the transformation of the Syrian American Medical Society (SAMS) into a globally-recognized medical NGO representing the Syrian American diaspora, serving hundreds of thousands of Syrian patients and refugees. He co-founded SAMS Global Response to address the refugee crisis in Europe, as well as the American Relief Coalition for Syria (ARCS), a coalition of 14 humanitarian organizations.
Dr. Sahloul is a leading advocate in the Syrian humanitarian crisis and the role of diaspora communities among medical circles, the media, the U.S. government, and the UN. He has authored many articles on the impact of the war in Syria on public health, healthcare workers, civilians, and children, and has been published in outlets such as the New York Times, CNN, WP, WSJ, Foreign Policy, the Chicago Tribune, and the Guardian.
With several fellow humanitarians, he founded MedGlobal, a medical relief NGO to dedicated to providing sustainable, innovative solutions to victims of global crises incorporating technology, cultural sensitivity, and interfaith collaboration.
He co-chairs the Illinois Business Immigration Coalition, and sits on the advisory boards of the Syrian Community Network (SCN) and the Center for Public Health and Human Rights at the Johns Hopkins University Bloomberg School of Public Health.
He is also an Associate Clinical Professor at the University of Illinois in Chicago.
Vincent Racaniello Ph.D in his own words:, “I am Professor of Microbiology & Immunology in the College of Physicians and Surgeons of Columbia University. Why am I qualified to teach you virology? I have done laboratory research on viruses since 1975, when I entered the Ph.D. program in Biomedical Sciences at Mt. Sinai School of Medicine of the City University of New York. My thesis research, in the laboratory of Dr. Peter Palese, was focussed on influenza viruses. That’s me in the black and white photo below, taken in 1977. Yes, I’ve changed.
In 1979 I joined the laboratory of Dr. David Baltimore at Massachusetts Institute of Technology, where I did postdoctoral work on poliovirus. The moratorium on cloning full-length viral genomes had just been lifted, so I proceeded to make a DNA copy of poliovirus RNA, using the enzyme reverse transcriptase. I cloned this DNA into a bacterial plasmid and determined the nucleotide sequence of the poliovirus genome. In an exciting advance, I found that a DNA copy of poliovirus RNA is infectious when introduced into cells. This was the first demonstration of infectivity of a DNA copy of an animal RNA virus, and it permitted previously unthought of genetic manipulations of the viral genome. Today infectious DNA clones are used to study most viruses.
In 1982 I joined the faculty in the Department of Microbiology at Columbia University College of Physicians & Surgeons in New York City. There I established a laboratory to study viruses, and to train other scientists to become virologists. Over the years we have studied a variety of viruses including poliovirus, echovirus, enterovirus 70, rhinovirus, and hepatitis C virus. As principal investigator of my laboratory, I oversee the research that is carried out by Ph.D. students and postdoctoral fellows. I also teach virology to undergraduate students, as well as graduate, medical, dental, and nursing students.
Since I think about viruses every day, and I have always been interested in teaching others about viruses, this blog seemed to be an ideal forum to convey some of my knowledge on this topic.
After starting this blog, I became interested in using ‘new media’ (internet-based media) to disseminate information about viruses. I’ve summarized my use of this format in an article entitled “Social media and microbiology education“, which you can find at the open-access journal PLoS Pathogens. In addition to writing about viruses on virology blog, I also host and produce five podcasts: This Week in Virology, This Week in Parasitism, This Week in Microbiology, This Week in Evolution, and Urban Agriculture. You can find them all on iTunes or at MicrobeTV. I teach a virology course each spring at Columbia University, and I post videocasts of each lecture at the course website, at YouTube, at iTunes University, and at Coursera.
If you would like to learn about our work on viruses in more detail, please visit my website at Columbia University, or my Wikipedia page. You might also like to follow me on Twitter or Google+, where I often provide links to interesting stories about viruses; on YouTube, where I posts videos about viruses; or on Instagram, or the This Week in Virology page on Facebook.”[/bios]