The Big One

THE BIG ONE:  OSTERHOLM

This book is a bit dense with lots of detail and an, “I told you so” attitude by one of the authors who predicted hundreds of thousands of deaths in the US late Spring of the first year of Covid and was criticized by his peers for being so pessimistic…….What follows draws from the book, TWIV (this week in virology podcast), and experience.

In my second year of medical school, as in all medical schools, my class studied the 1918-1919 World wide influenza pandemic That catastrophe killed many more people than had died in WWI. A conservative estimate of deaths related to that outbreak is 50 million people. As many as 100 million may have died.

We were told to expect just such an event during our careers.

The management of the Covid epidemic in the USA, and everywhere else, was less than perfect—how could it be otherwise because to get it perfect would mean some serious fortune telling and then convincing lots of contrarians you have the answer. Management by committee, which is what we saw in the USA did not go well. Caveat: epidemics do not bring out the best in people. Planning in the USA for over a century,  the assumption was always that, “the big one” would be a flu virus. In the first two decades the twenty-first century, there was a new contender: Covid viruses. Most of us did not hear about these outbreaks because they were controlled with traditional public health measures: contact tracing and isolation of the infected. Both epidemics died out. They we’re frightening for their potential: in 2002 with 9000 infected and roughly 10% dying SARS 1 made its entry. It came from China, not Wuhan though, from a city with a large outdoor wild animal market. There was another in 2012 MERS Covid with a 35% death rate.

Covid 19 was identified in late 2018 in China and there were reactions:

Travel was restricted, first in China and then the world—too late.

Working assumptions were that symptomatic people would be identified and isolated—hence temperature screens in airports. What was not sorted until May of 2020 was that otherwise healthy appearing people could be infected and spreading the disease. By the time travel was restricted anywhere, it was too late. The official closing of transportation in China was when cases had been identified in Italy and Washington state.

Testing: The Chinese, with an epidemic on their hands, went to work and by January published world - wide, the genome of the virus allowing labs all over the world to start work on studying treatment and vaccine options.

Early test kits in US were not terribly accurate and testing was mostly done on the sick and people in contact with the sick. One had to go to centers for testing ie there were no at home kits until much later. Inadequate testing of even healthy appearing people was a lapse often criticized in the developing pandemic. Official recommendations were slow to change in this respect.

MASKING-Asians have masking against respiratory infections as a cultural norm, so this issue was not very important in Asia but in the US, there was obviously mixed messaging on who, when and why masking was appropriate and that advice changed over time. Once more, the thinking behind recommendations for many was not especially compelling.  Initial thinking was the virus spread through droplets associated with talking, singing, and coughing—hence six foot spacing and barriers in offices when face-to-face discussions were needed. It turned out that simply sharing air in a room with others could be a significant exposure regardless of distancing recommendations.Once the aerosolized nature of this virus’ reach was understood, simple cloth and surgical masks while better than nothing, did not offer that much help when in a confined space with others—-Only the N95 fitted to the user (I had an option to have one fitted and the set up required that I be clean-shaven; I declined as my contact with people was limited) and changed often provided dramatic protection—and this resource was scarce and appropriately diverted to first responders.

ISOLATION AND QUARANTINE: as a public health volunteer, I did some of this work with many others and we hit a brick wall: trying to get people to isolate when exposed is a preventative strategy and no longer helpful when huge numbers of people were infected; once more, common responses we’re those of incredulity. “I don’t feel sick. I have to work. I don’t know anyone with this condition and the contact you identify, well, I was hardly near them……” We had no authority and could only encourage isolation. In other countries, the interventions became draconian—A friend living in France let me know that there were isolation orders to the general population and anyone more than a kilometer from their home would be given a 100 euro ticket. Time out of doors was limited to a half hour a day, and so on. In China, welders closed gates that effectively confined people to apartment complexes.

Such measures which included closing schools and social gatherings are tools not to be dismissed. Data from 1919 show dramatically different courses of death in city populations in the US depending on which measures were used and how early they were put in place. These measures saved lives in 1919. They were as dislocating and unpopular then as they are now and just as in 2020 they were not uniformly adapted—death rates at the peak of infection was dramatically different in New York vs Philadelphia in 1919.

Communication by authorities reflect for me, some of the most dramatic dysfunction during the pandemic. It was done in real time with a universe of commentaries across many formats, all critical. The CDC pronouncements read like they were created by a bureaucratic committee (they were) and did not inspire anyone. They changed without convincing reasons even though there may have been an internal logic. They tried not to panic people (the author of the book was criticized for forecasting too pessimistic a number of deaths but which proved accurate). The president led cheerleading often  in conflict with CDC and other officials (Jan 22: “We have it totally under control….” Or Feb 10: “Looks like by April, you know in theory when it gets a little warmer, it miraculously goes away.”). This facilitated the INFODEMIC: scrolling endlessly opinion to opinion and never coming to a clear conclusion, feeling insecure about what to do, and often making imperfect decisions.

The vaccine came to us in amazing time—my experience was that it was liberating and allowed the more draconian measures to be relaxed. It proved to be an imperfect vaccine. While incredibly safe compared to many other vaccines we all have had, and clearly superior in that regard to having the disease itself, like all vaccines, it did have side effects and defying expectations, did not provide permanent immunity. On reflection, we don’t get permanent immunity from flu vaccines either…..

Traditional public health philosophy is designed to manage the country as a country (or a state as a state) and not focus on individuals. This happens in wartime as well. This remains a fundamental conflict politically and socially going forward.  Everywhere……

Did anybody get it right?

The Chinese initially controlled the infection for nearly 2years by using draconian shut downs. Travel within China was restricted and people we’re forced to stay inside their homes. This may have catalyzed other countries to follow this lead of aggressively trying to confine the disease. For me, China being the epicenter of the infection and taking these measures found me wondering, “What do they know that they aren’t telling us?” In the end this policy was abandoned in China secondary to population unrest and the faltering economy. There was a dramatic spike when the country opened up—huge numbers got ill and died. We will likely never know how many.

The Swedes famously did not lock down like other Scandinavian countries, and their numbers looked bad the first couple years but with time, they are not clearly that different from other European countries. The US has 50 flavors of specific policies and approaches to disease management to choose from.  In the end our national statistics are in the same ball park as those of  Europe.

Scandinavia did better than other first world countries even though the individual countries used different strategies: why? Social cohesion and a sense of trust in the government is one hypothesis. They played nice.

PROBLEMS FOR NEXT TIME: One of my favorite historical scenarios is Randy living in Roman Britain around 410 AD. The Roman administration left England: no army, no civic structure, no maintenance of the infrastructure, and the Saxons are coming…..A new world wide pandemic with an airborne “novel” or previously unknown infection comes. What can you do to protect yourself until a government organizes its response with resources you don’t have?

Before a vaccine is developed: There are painful choices, none of them easy.  For a virus like covid, the bottom line is, “don’t share air.” This requires adjustment in many routines: work, socializing, church, work, and schools. When outside in an uncrowded environment, you are mostly OK but in enclosed rooms, sharing air, you need to mask up or find a way to get the work done outside that room.

Should your kids go to school? If like covid, they are less likely to get ill, they remain likely to get it and bring it home. Kids are “sewers” of infections of all kinds when attending school and always have been for every virus out there. It is helpful for working parents to have children supervised in school.  Accept that or isolate them knowing that one study showed that 70% of adults getting covid who had kids, got it from their kids! For a low kill rate that might seem acceptable but early in an new epidemic, you don’t know exactly what that risk is.

Should you go to work? Your employment may require it; don’t share air and if you have to go to work, the only mask that protects completely is the N95 fitted to you—worn when sharing air— changed to new ones with some regularity. Without it, surgical and cloth masks prevent sharing the virus in droplets but are imperfect for the virus airborne on “wings” like Covid.

We stock up and prepare for the “big one” meaning an earthquake. Consider what supplies to lay in for an epidemic that may spread through air (masks) or secretions (gloves and masks and cleaning solutions). When you have a cold, consider masking up for practice and normalize that practice with friends, family, neighbors. Consider stocking up on things likely to have a “run” in the early phase of a pandemic (toilet paper comes to mind…..).

I am an unapologetic vaccine advocate; Weigh the pros and cons of your getting the vaccine and come to terms with possible side effects vs getting the disease. Consider that while not ill with the disease, when unvaccinated, you spread the disease more readily.

Consider the actual risk of your decisions: what if, like the 1918-1919 flu pandemic, 50% of deaths were in people under 40 years of age—or if it affected children the way polio did. Would that reality change your personal decision-making about masks or isolation?

Think about your trusted information sources; do not doom scroll — it is habit forming, it is depressing, lends to indecision , and often is bad information.

Consider: would you rather be right or effective when lives are on the line: after the vaccine was available over a two year period, Registered republicans were 40% more like to die than registered democrats.

What about the Government-what can it do?:  if you don’t like big government, you won’t like this.

The public’s awareness of how bad things can get were a world wide phenomena; with lock downs over time they became clear:

social isolation, depression, spousal abuse, alcoholism, loss of learning opportunities for school aged children, medical avoidance of screening and treatment opportunities. In addition, the economic suffered; there was recesion with supply shortages, food shortages, and business failures. By May/2020 15% unemployment (USA).

Whatever the Gov does, it will be thinking of all these things and hopefully working to find the sweet spot, protecting the population’s health while trying to maintain basic function in schools, and the economy.

It is costly to prepare for war. It is costly to prepare the for the infectious “big one.”

Research and development is key—intel if you will—as is sharing information across borders. Of all countries, China did this early and that gave everyone a leg up on reacting to the virus in many international laboratories. We spend lots of money for military applications some of which age out without much use. Investing in research on diseases that can cause pandemics is expensive but much less expensive than Osprey aircraft (as an example) with dividends ie lives saved for which there is no comparison.

Supplies (masks, gowns) should be pre loaded and distributed as are military supplies around the world.

It is a national problem; we had 50 states with different rules and reporting; the Federal government asked the states to manage this pandemic as they saw fit. This caused dysfunction: some states refused to send data to the CDC. Within states, data was not shared. States fought over scarce resources even when other states had a greater need……We don’t win world wars with state militias each plotting its own strategy. We won’t effectively counter “the big one” without a national strategy.

Fog of war; the situation may change on the ground—track it and adjust and this may vary region by region; I had a map at one point of Covid that had the old South lit up. I wanted to editorialize why this might be so but this was a transient picture of the spread and the virus made its way to every region in time. Resources and strategies need to adjust based on “local” conditions.

Assume people will not comply—flexibility of response is needed with a rational bottom line. Covid after five years makes a telling point. In first world countries, protecting the vulnerable was a laudable goal but in the year before the vaccine, and after, it became clear that many of the vulnerable would get the disease despite protections.

Communication: ideally, the Government will develop a credible communicator loaded with up-to-date information: think Fireside chats…..every couple weeks. The information should be clear, concise, with an over-arching rational clearly in front. Such a person could address disinformation without disparaging desperate people.

For all of us and the government: Remember that ambiguity and insecurity are the norm early in an epidemic. Epidemics do not bring out the best in people.

Interesting resources:

"Plague at the Golden Gate", an episode from the American Experience series. The documentary explores the 1900 bubonic plague outbreak in San Francisco, focusing on how anti-Asian sentiment and political factors hampered the public health response. Many of the issues from that time will be recognizable given our recent experience.

THE GREAT INFLUENZA: John Barry—the definitive re telling of the world wide pandemic of influenza in 1918-1919. BTY: it was not “the Spanish Influenza" but rather, the American virus……..