COVID- 19: A Point of View
Origins of the Virus
Most of the evidence now points towards a “wet” market in Wuhan, with bats being butchered for human consumption, the most likely source of COVID-19. These markets form an integral part of Chinese culture and social life. And part of their tradition is to consume ‘warm meat’ – from animals that are killed on the spot (and sometimes cooked alive). The fact that they also consume many exotic wild animal species (pangolins, civets, foxes, bears, snapping turtles etc) also means there is inter-species contact that would never occur in the wild, which can lead to viruses adapting to try to infect another animal species.
It is human intervention that is the problem here. The Chinese Government allows these animals to be bred on farms, in order to satisfy the demand for live animals in wet markets. And so zoonotic viruses (which can be transferred from wild animals to humans), are given the opportunity to infect humans, or other animal intermediaries. So, if you are an ambitious coronavirus with a penchant for international travel, the perfect vector is the human with an air ticket. Peter Medawar described a virus as “bad news in a protein envelope” and he was dead right.
When the virus began to spread the media (especially social media) began to create a climate of fear. Constant use of the expression “killer virus” helped create a sense that something was on its way – a marauding monster that could envelop everyone – but especially the old and those in poor health. And there is the usual litany of absurd anthropomorphisms: I have heard the coronavirus variously described as “sly”, “ruthless”, “hateful”, “smart” and “determined”. I am also told that it “knows what it’s doing”. Over the weeks this sort of reporting has grown into a frenzy – so that hysteria became the prevailing mood. Humans, after all, have a deep aversion to two things: uncertainty and death. And in just 2-months the coronavirus has brought humanity face-to-face with both.
And of course, it is fear of death that drives this mood of apocalypse. If we knew for sure that the virus resulted in a couple of days illness for everyone, with no excess mortality, no one would care. It’s the reportedly high case-fatality rate (3-4% or higher in the UK and 8% in Italy), that gives the whole thing traction. But what should we make of these numbers?
The Numbers
The short answer is – not much. Despite being warned against it, the press continues to make invidious comparisons between one country and another. We are told that we are on the same catastrophic trajectory as the Italians or the Chinese were at the same point in their epidemic. This is absurd – not least because these health systems, populations and geography of these countries, are very different. And most experts are quite sure that China has consistently under-reported the epidemic in Wuhan.
The fact is that because there is no single accepted definition of a COVID-19 “case”, any talk of comparisons is meaningless. Some countries count COVID-19 as the cause of death, even if the patient just happened to test positive and had no symptoms. And there are endless other variations on this, introducing potentially large ascertainment bias and measurement errors.
What about the mortality rate? You can only measure a rate, if you have a numerator and a denominator. In this case we know (or know roughly) the numerator as the number of deaths from COVID-19, though here there is likely to be significant over-reporting. Then you need the denominator – the number of individuals with the disease. And to this, there is simply no answer – because we don’t test. In Germany they have tested huge numbers and they have a case-fatality rate of 0.3%. So, we should ignore the claimed mortality rate for COVID-19 here in the UK – currently around 8.6%. It’s based on an assumption that (as of April 2nd), 2921 people have died and 33, 718 people have the disease. But this is just wrong. My guess is that around 2 million have it, in which case the mortality rate based on current deaths is around 0.2%. But since we are not testing, this is just a guess. As one epidemiologist has said, “without testing we don’t know whether we are out by a factor of 3 or 300”. And to make it even more complicated, it seems that at least a third of people who have had COVID-19, are simply not aware of it.
What we really need to know, is not so much the number of deaths, but the excess mortality rate; in other words, among those who contract COVID-19, how many had serious, life-threatening or terminal conditions that would have shortened their lives anyway? We don’t know the answer to this, but it’s a critical question and surely should inform our response to the COVID-19 pandemic. Professor Neil Ferguson, one of the Government scientific advisors, concedes that up to two-thirds of COVID-19 victims, may have died this year anyway. In Italy, only 12% of death certificates listed COVID-19 as the direct cause of death.
And finally, there is the question of the age of those dying from COVID-19. We hear sensational headlines about young people having been “killed” by COVID-19, with “with no underlying health issues”. One good recent example was that of an unfortunate 21-year old woman, but who was subsequently shown not to have been infected with COVID-19 at all. Importantly, we are not given the age distribution, the number in each group, breakdown by gender etc of those who have died. We are sometimes given an age range – as recently when the total deaths for the day were given as occurring in individuals aged 13-98 years. But this is meaningless. We need to know the mean – or preferably the median age of those who have died.
So, in summary, we have almost no data on which to make any meaningful statement about where we are, let alone predictions about where we will end up.
The Government Response
The Government (and this is not a party-political point) has been woefully under-prepared and behind the curve from the very beginning. When the outbreak was reported in Wuhan, the scientific group advising the Government (Professor Neil Ferguson et al), advised that it would not be too big a problem for the UK. Moreover, we were reassured that the NHS was ready and prepared for all eventualities. We were told this repeatedly by government ministers. This led to weeks of dithering until, finally, the light went on. But from then on, the government was playing catch-up – and it’s still way behind.
For example, regarding testing, on the 19th March Boris Johnson said we would soon be up to 250K tests a day, a target repeated by Matt Hancock and repeated on 25th March. On 1st April they say they have managed 10K (though this is disputed) and they have now set a target of 25K by mid-April. This, even though testing is fundamental to getting the epidemic under control and that it is perfectly possible to purchase a test online today. In terms of ventilators, personal protective equipment (PPE) for frontline workers and countless other areas, the government response has been slow and painfully inadequate.
The initial public health policy was one of ‘mitigation’ and ‘herd-immunity’. The idea was to isolate the elderly and vulnerable and to allow the disease to move in a graded way through the younger sections of the population. Estimates suggested that up to 20% of the workforce could be absent from work at any one time, but this was viewed as manageable. When the virus had run its course, the older and vulnerable could be re-introduced. Whilst it’s true that some younger members of the population would succumb, this is always true of any infectious disease. This strategy is the one currently being followed by Sweden, though it is too early to know whether it will be successful.
Unfortunately, the mass-hysteria (a consistent feature of epidemics) made any rational discussion of the ‘mitigation’ approach, all but impossible. Sir Patrick Vallance was condemned as unfeeling and the Tory government as uncaring about the elderly and vulnerable – just locking them away. In addition, the Ferguson group warned the government that if they pursued this policy there could be 500,000 deaths but changing tack could reduce it to 250.000. But there are about 600,000 deaths in the UK annually and the Imperial group did not attempt to quantify how many of the projected COVID-19 deaths would already have occurred in the 12-month period. In any event, these numbers proved to be wrong and Ferguson and his group subsequently revised them down to 20,000. But this did not prevent the government move from mitigation to “suppression”; effectively a decision to lock everyone up and – more (much more) contentiously – to crash the economy.
The really difficult question is whether the price to be paid will turn out to be worth it, or whether it is a hysteria-fuelled over reaction on the part of the public, to which politicians have too easily acquiesced. The public does not pause to consider whether such actions will work, much less the long-term consequences. They just want the government to do something. For the politicians, there is a difficult calculus; how many deaths are acceptable? Should we save the lives of the older and most vulnerable, many of whom have limited life-expectancy anyway, at the price of destroying an economy, ruining the hopes and aspirations of the younger generation and saddling the country with massive debt for decades?
And, as all the evidence shows, there are big health costs consequent upon a massive economic downturn, which may result in an excess mortality rate which far exceeds anything directly attributable to Covid-19. A recent report from Goldman Sachs, suggested that the US economy would shrink by 34% with 9% losing their jobs. For each 1% job reduction there would be 36,000 excess deaths due to poverty and social deprivation, drug and alcohol addiction, cancer, mental illness and a rise in infant mortality. Note also, that unlike COVID-19, many of these deaths will occur in the economically active age-groups.
I think that future generations will regard the self-inflicted damage to the economy as an entirely avoidable catastrophe. But it’s not all bad news.
Reason for Optimism!
- Like all pandemics, the COVID-19 crisis will come to an end. As more and more people get the infection and move into the general community, the herd-immunity will build.
- My guess is that this will happen at a slightly quicker rate than has been predicted, because I think COVID-19has been around for much longer than has hitherto been appreciated. A self-testing kit would be a game-changer. More of who have been infected and didn’t know it, can begin to get back to normal – possibly being issued with an Immunity Certificate.
- The NHS will weather the storm, despite the poor response of the Government. I think the total number of deaths genuinely due to COVID-19, will be under 20,000 – on a par with seasonal flu.
- I also think a vaccine will be available earlier than the 18-months currently being discussed – maybe before the end of the year.
- A quicker route to protecting the vulnerable and high-risk groups, could be through the introduction of Convalescent Plasma Therapy (CPT). This essentially involves taking serum from individuals who have recovered from COVID-19 and who have developed immunity. By injecting their serum into high-risk patients with infection, it is believed that this will reduce the severity of complications and improve the chances of survival. A recent study from China has shown that this is a potentially exciting area of therapy, though large trials are needed.
- Most analysts say that the economic downturn will be very severe and bring in a short recession, but that recovery will be quite quick and most of the losses will have been corrected before the end of the year.
- The drug treatment of COVID-19 will also become more evidence-based – several agents that look promising are currently in trials and may come into general use.
- There is a strong international consensus among scientists and physicians (including those in China) that wet markets must stop and come to an end. But as I write this, I am quite sure that many wet markets in China continue to operate and, thereby, pose a threat to global health. Of course, China is not the only culprit; these markets exist in Vietnam and other parts of South-East Asia.
- There will be enormous international pressure on China to crack down hard on these wet markets. This will be in the form of economic pressure – which in the end will be far more persuasive to the Chinese than any sanction provided by the WHO. So, I think you will see change, slowly at first – probably in the form of more onerous regulation and legal penalties - but the direction will be unmistakeable.
One final thought
We have created a global, human-dominated ecosystem that provides a uniquely favourable environment for the emergence and spread of highly contagious viruses such as COVID-19. It will not be the last. We have tended to regard the whole of nature as a resource for our consumption or entertainment. We have assumed all along, that we were in control. Then in the space of 8-weeks, a microscopic, primitive bit of molecular machinery, has entirely flattened the world economy and frightened its citizens into a state of hysteria. The lesson is clear: we are not in control.
Some American Evangelists have said this is “God’s revenge”, but it is more likely Nature’s response to human hubris. Perhaps we can learn from this to be more heedful of Nature and stop treating its creatures simply as resources to dispose of as we wish. And if the beneficial effects of the current crisis on the environment, show up as it looks like they will, then this may prove to be a turning point in human history. We shall see.
Dr David Ashton MD PhD 3 April 2020
