COVID-19: Not solely a public health issue

Corona viruses are very common. The common cold is one type.

By SHLOMO MAITAL
COVID-19: Not solely a public health issue (photo credit: Courtesy)
COVID-19: Not solely a public health issue
(photo credit: Courtesy)
What is COVID-19 and who named it?
It is a type of virus, known as coronavirus, so called because its shape is like that of a crown (“corona” in Latin) or like the corona (outer atmosphere) of the sun.   In early February, the World Health Organization officially dubbed it COVID-19 – CO and VI  come from "corona" and "virus,"  D from "disease" and 19, from the year it was born.
Corona viruses are very common. The common cold is one type. COVID-19 is worse, because it can badly damage the lungs, in some cases so badly that the body"s vital organs do not receive oxygen and the ill person dies.
 
How do viruses make us sick, and how do they spread?
Viruses are not actually living things. They cannot reproduce and spread on their own.  They propagate by invading living cells and by using the cell"s DNA to replicate the virus, in thousands of copies.  (Viruses are a bit like the cuckoo bird – the female lays its eggs in the nests of other birds, destroys one or two eggs of the host parent bird and replaces it with her egg. When the baby cuckoo bird hatches, it attacks the other baby birds and kills them). 
In some eight hours after a single virus infects a human cell, that cell can produce between 100,000 and one million new virus particles.  Only 1% of those can infect other cells. But that still means between 1,000 and 10,000 functioning viruses spread throughout the body.
Human immune systems are pretty good at battling antigens (foreign invaders),  but viruses have clever ways for evading the body"s defenses and penetrating cell walls. Vaccines help the body resist the flu, for example.
As I write this, there have been some 120,000 cases of COVID-19 worldwide and over 4,000 deaths.
 
How do flu vaccines work?  Will we soon have a vaccine against COVID-19?
Flu vaccines stimulate the body"s immune system to make antibodies that attack the flu virus in our blood stream.  Many companies are working on developing a vaccine against COVID-19 but experts think this could take up to a year, because extensive clinical trials are needed to ensure the vaccine is both safe and effective. 
 
Where did COVID-19 start?
In Hubei Province, China.  It may have been transmitted by bats, which incubate viruses but apparently do not become ill or die from them, to pangolins, armadillo-like animals, sold in markets for food. On  December 29th  Chinese authorities identified a cluster of similar cases of pneumonia in the city of Wuhan in China. The cause was COVID-19.   
Is COVID-19 a pandemic, or just an epidemic?  Have we had similar pandemics in history?
Pandemic is a word from the Greek:  pan, meaning "all" and demos meaning “people”.  The WHO defines pandemic as “an outbreak of a new pathogen that spreads easily from person to person across the globe”.
An epidemic is a disease actively spreading, usually within one country. So by these definitions – yes, COVID-19 is indeed a pandemic.  Political leaders have been reluctant to use that term, lest they frighten us. Modern history explains why.
There have been four pandemics in the past 130 years: in 1889, 1918, 1957 and 1968.  In 1889-1892, an flu virus came in three extended waves. It began in Turkestan, in May 1889, reached Berlin and Paris after several months, then in a few weeks crossed the ocean to the US, then to Hong Kong and Japan. There was a second wave, mainly transferred by ships. The third wave began in October 1891, making it a true pandemic, and it lasted until the spring of 1892, and it was the most lethal. We don"t know for sure how many died; the numbers were doubtless large.
In 1918, the first influenza cases emerged in the US in January, in Kansas, spread rapidly in US Army camps, and by April it was spreading through Europe. [Dubbed "Spanish flu", it was a misnomer; it did not originate in Spain].
The first wave disappeared in the US but had spread to Asia and Europe. The second wave occurred in late July in Switzerland and by mid-October most of the world’s cities had experienced this deadly wave, and it did not die out.  The third wave spread from January-April 1919 and caused a third of the total deaths. Mortality was estimated in the order of 10% of those who contracted the flu. 
Experts believe that in total the 1918 virus killed between 1.9 and 5.5% of the total world population; more than half the dead were young adults. The estimated total number of deaths totaled between 34.4 million and 100 million.  One of those who died was my grandfather, Yisroel Arie, after whom I am named; he succumbed in Pittsburgh, Pennsylvania.
In 1957 “Asian flu”, H2N2, began in late February in China, became epidemic in Hong Kong in April, and then reached Japan. It spread worldwide. Outbreaks occurred in the US from June through October; the “influenza-related mortality rate was extremely low.”
There was a second wave in January to March 1958, with deaths totaling 20,000. A third wave, January to March 1960, had a sharp peak, quick falloff, and 26,000 deaths. Some 20-25% of the deaths were caused by viral pneumonia.
In 1968, the H3N2 virus began in Hong Kong, in July, and reached the US, and Japan, in August, and Britain, in September. The first wave peaked in January 1969; the second wave, a year later. Morbidity was around 20%. Mortality in the US was estimated at 34,000 people, compared with a baseline mortality from seasonal influenza of some 20,000 – but there were few cases of viral pneumonia. This was the mildest of the four pandemics.
The Severe Acute Respiratory Syndrome outbreak in 2003 was defined as an epidemic, but not a pandemic. In 2009 swine flu (H1N1) was defined a pandemic but it was considered a relatively mild version.     
How deadly is COVID-19?
So far the statistics indicate that 80% of infections are mild or asymptomatic, 15% are severe infection, requiring oxygen and hospital treatment and 5% are critical infections, requiring ventilation (a machine that breathes for you or helps you breathe).
The mortality ratio (the number of reported deaths divided by the number of reported cases) is between 3-4%.  This compares with the mortality rate for seasonal flu, which is about 0.1%.  Elderly patients and those with respiratory problems or compromised immune systems suffer higher mortality from COVID-19.
 
What can we learn from US experience and policy regarding COVID-19?
Act early, act fast, act decisively, to contain it.  The US failed to do so.  According to Sheri Fink and Mike Baker, writing for the New York Times, a research project in Seattle, Washington, “tried to conduct early tests for the new coronavirus but ran into red tape before circumventing federal officials and confirming a case.”  A golden opportunity may have been lost to contain the spread of COVID-19.
Some 25 people have died in Washington state from COVID-19, many of them at a home for the elderly in Kirkland.
 
Are Israeli public health officials acting wisely in dealing with the pandemic? And who is in charge anyway?
Who is running the coronavirus pandemic show in Israel?   I think it is pretty obvious – it’s the doctors, medical experts, epidemiologists and public health officials.  As it should be. Right?
No, I’m not so sure.  Initially the focus worldwide was on stopping the spread of COVID-19 from China to the world.  That pretty much failed, as expected – with millions of people travelling every week and with some countries reluctant to share information, drastic quarantine measures came a bit too late.
And now, COVID-19 is in over 100 countries with laboratory-confirmed cases. This, despite cancellation of flights. So – it has spread. Now what?
Public health officials are in charge. And lacking medicine or vaccines, their tool is mainly that of quarantine. In Israel, a small country, with relatively few causes of new coronavirus, some 100,000 people are in self-imposed quarantine, for two weeks, largely because they have been in countries like France and Italy, where coronavirus existed.
Quarantine may be rather ineffective in halting the infectious spread.  And it is disastrous for the economy.  You cannot simply shut down the world economy – people have to eat and drink and keep the wheels of commerce moving.  It cannot really be done efficiently from home… the Internet is not yet up to it.
So who is running the show?  What we need is a small, powerful interdisciplinary team made up of political leaders, public health experts, epidemiologists, and yes, perhaps economists, and psychologists, and information experts, who will focus on the system – the big picture.  How to deliver accurate information.  How to weigh cost-benefit in quarantine policies.  How and when and whom to test for COVID-19.  How to deal with public transportation and flights.  How to run schools.
You could in principle simply shut everything down and tell everyone to stay home.  That would be disastrous, immensely costly, and harmful to the mental health of the nation. I do not believe this is an option. So the question is, how to keep things running more or less smoothly, in the face of the coronavirus that is here to stay?  For that we need a systems approach.
This is all new territory. We have not faced a real pandemic, post-1989 global economy.  Each country needs an integrated team to make policy, and the world needs a similar integrated team to coordinate policies among nations.
Let us heed the wise words of Prof. Zvi Bentwich. He is an Israeli doctor who teaches and researches at Ben Gurion University, in Beersheba. 
Before quoting his views on COVID-19, let me establish his credentials first.
Bentwich serves as the head of the Center for Emerging Tropical Diseases and AIDS at the BGU.  He founded the first AIDS center in Israel in the mid 1980s. His groundbreaking research uncovered the link between Neglected Tropical Diseases (NTDs) , particularly intestinal worms, and immune system deficiencies, pioneering the concept that NTDs play a major role in the pathogenesis of HIV/AIDS.  He is a leading advocate for public health and human rights.
So, clearly, this is a public health expert who is worth listening to.  Here is his position, printed in Haaretz:
The heading on his Op-Ed piece:  “Tight border isn't the answer to virus.” “The Israeli government recently announced that everyone returning from abroad must undergo self-imposed quarantine for two weeks.  Everyone? Yes, probably so that Prime Minister [Benjamin] Netanyahu will not appear to be singling out the US, thus angering his friend and colleague [President] Donald J. Trump. Such quarantines were already in effect for most travelers incoming from Europe.”   
Bentwich asks,  “Is there an alternative approach to fighting the disease right now?  [i.e., an alternative to closing down the borders and shutting down the economy for weeks and weeks?] Yes, it is called mitigation. It involves using less drastic methods that are likely to yield similar results regarding the damage caused by the virus but that significantly reduce the negative social and economic consequences of containment.”
Mitigation. Not decimation of our economy.
This is coming not from me, an economist but from a distinguished physician, an expert on virus containment.
“The coronavirus too will pass and until it does the damage should be minimized as far as possible. We must accept the possibility that it won"t be the last viral epidemic and that it’s important to find the optimal way to cope with such epidemics, at a reasonable cost”, Prof. Bentwich urges.
Perhaps, if something good will emerge from the COVID-19 crisis, it will be the understanding of how interdependent all of us are, everywhere, and how concrete and steel walls between countries are not the answer.
On the bright side, we Israelis have all been through major crises before.  We are a resilient nation and we will respond to this new virus with wisdom, patience, courage and altruism, helping one another and above all avoiding hysterics and panic.
 
The writer heads the Zvi Griliches Research Data Center at S. Neaman Institute, Technion and blogs at www.timnovate.wordpress.com