While we can certainly rejoice at the increasing amount of vaccines being released in the fight against covid-19, there is still considerable risk as at the same time, we are experiencing new variants of the disease developing across the planet. Europa United’s Brian Milne warns that we must not take our eye off the ball and remain vigilant.
Hans Kluge, WHO Europe director, made a statement a few days ago in which he said that while the arrival of vaccines presented European nations with ‘new tools’ to fight covid-19, nearly half of 53 countries in the Europe and Western Asia region had reported an incidence rate of more than 150 new cases per 100,000 people over seven days. A quarter of those countries had recorded more than a 10% surge in cases over the same week. As he put it for the WHO, Europe is at a tipping point in the course of the pandemic, warning that the SARS-CoV-2 is spreading rapidly across the continent; the arrival of new variants, he added, has created an ‘alarming situation’. He also said that countries rolling out the Pfizer/BioNTech vaccine can be flexible on the gap between first and second doses, that is to say a balance should be struck between utilising limited supplies properly and protecting as many people as possible. This article bears those considerations in mind whilst not losing sight of the fact that whatever the situation, this is a global pandemic and what goes for Europe goes for the rest of the world as well.
History tells us that human beings have faced epidemics, pandemics, famines, floods, earthquakes, genocides and other disasters before, but this time coronavirus has set a precedent in contemporary society by being there in most nations in the world. Thus, saying it is ‘unprecedented’ is not entirely correct but a number of things including how it has been politicised are. There is absolutely no doubt that the consequence of this covid-19 pandemic has changed many things such as making handshakes or the affection kiss and hug as forms of greeting each other proscribed, to the measures including putting entire countries in lockdown. We human beings have always had diseases that vary from the very mild and tolerated like the common cold that may also reach numbers we can define as pandemic to diseases such as poliomyelitis that is close to being wiped out. So a question must be whether covid-19 really is that different to other illnesses? It has had bizarre consequences, such as turning toilet paper into a commodity that was bought in bulk to hoard, irrationally, to bunker mentality stockpiling of foodstuff.
Now that vaccine has begun to be used and some kind of improvement may gradually begin the question as to whether or not that is the end of the ‘tunnel’ remains to be seen. Will it be some kind of cure or be like the annual influenza jab on offer because covid-19 has become an established part of life that we must deal with to at least keep under control? There are other questions to be answered about slow government responses that have given the virus free rein to infect countries far more than they might otherwise have done or why the possibility of a pandemic that was anticipated for some years by medical experts had not prompted preparations for the event of them occurring? There is a long list of questions no doubt, many yet to come. People deserve some answers.
The risk to each of us
It is not that difficult to say who might be at the highest risk from any particular disease. The reasons are quite clear, for instance somebody with severe asthma is at risk when there are respiratory viruses that most commonly circulate on all continents as endemic or epidemic agents that include influenza outbreaks, rhinovirus and now coronavirus. If we look at the 1918 influenza pandemic it was dissimilar to most annual outbreaks because it was generally fatal in people aged between 20 and 40 more than it was in older people. Two reasons have been identified. The crammed together living conditions of soldiers at the front or in barracks waiting to be sent to the front during WW1 was probably the main cause. Immunity built up by older people who had been infected during previous influenza outbreaks is the second. Now there is variable severity of covid-19 that has thus far affected older people, particularly those in care institutions, where proximity was the ideal situation for outbreaks and initially poorly diagnosed thus leading to high death rates. In reality, there is less clarity on vulnerability by age, especially the new strains that are symptomatic in younger people who were initially considered not to suffer from the virus.
There is no precise demographic that describes who is at zero risk of dying from covid-19. A considerable number of variables have been linked to higher mortality rates. People older than 65 are considered to be at greater risk than young people; men are more likely to die than women and members of ethnic minority groups tend to have the most severe cases. It is as yet not clear why this is the case. It is still unclear why various underlying conditions that include coronary heart disease, respiratory conditions and diabetes, increase the likelihood of dying from covid-19. Similarly it is unknown why some people have lasting symptoms that we now call long covid, yet others whose pre-covid health might make them the most likely to have long term problems are not. As yet there are only hypotheses to explain observed patterns and inconsistencies, thus we still have no clue why one person infected with SARS-CoV-2 becomes severely ill while another person shows no symptoms at all.
The baffling evolution of the virus
At first it was considered absolutely certain that this pandemic began in or near Wuhan in China. There is now some doubt about Wuhan on the basis of cases quite a lot earlier than any word from China about an outbreak in the Hubei province, in more than a single place in the world at that. Otherwise, if Wuhan is where it began, the SARS-CoV-2 virus is most likely to have originated in bats in Hubei, a species most likely found not too far from Wuhan and sold for food on the market. There are parallels with the origins of human immunodeficiency virus (HIV). The covid-19 pandemic has shown many similarities to the HIV pandemic in 1981, from the fear of treating patients for a virus we have little knowledge of, to analysing how the levels of the helper cells that are white blood cells, an essential part of the human immune system, often referred to as CD4 cells, T-helper cells or T4 cells. The ones known as CD4+ T play an important role in adapting immune responses to pathogens and are important in collation of overall immune responses. CD4+T is affected in both diseases.
At present SARS-CoV-2 is treated as very different to the two species of Lentivirus which are a subgroup of Retrovirus that infect humans, but are known to have originated in primates hunted, sold and eaten as ‘bush meat’ in West Africa. However, the infection of CD4+T cells, those so-called helper T-cells that aid immunity, by the two Lentiviruses was probably present for many years, perhaps several generations, but mutated into its HIV causing variant once it had left Africa and infected people who carried no immunity against them. That is one of the most important sources of knowledge we have about the highly adaptable virus causing the present pandemic. Scientists, in the massive confusion about this coronavirus, know that the SARS viruses that caused SARS and MERS are highly adaptable, able to cross species and immune system types relatively quickly. The first strain of the SARS coronavirus species identified was SARSr-CoV that caused the SARS epidemic. Its origin was an intermediary version in palm civets that was transmitted to and mutated from horseshoe bats in Yunnan. Coronaviruses belong to a related RNA virus group that cause such things as common colds, Dengue, measles, hepatitis, Ebola and rabies, that are all closely related to the Retrovirus group with which the virulent and highly adaptable SARS species belong.
Thus, the probable origin in a particular species is known, intermediaries such as the pangolin that has been in and out of the covid-19 theories may be that vector. However, they are imported, not indigenous to the area in which the suspected bat species lives, so how transmission may have happened remains an open question including pangolins actually being infected by human beings keeping them to butcher for sale on the market. People who showed symptoms exactly matching covid-19 in several places, including much earlier than in China and not known to each other in Italy, have been identified but well after they were ill. So there is also good reason to believe that these people had contact with carriers who possibly remained asymptomatic or were only mildly ill, thus diagnosed as having influenza, who may have been infected during a visit to Wuhan, exposed to the bats, pangolin intermediaries or people with the illness before it became as virulent.
The timing is still an open discussion. A report hosted on the medRxiv server of Yale University in June 2020 told how SARS-CoV-2 was detected in Barcelona sewage long before the declaration of the first covid-19 case in China, demonstrating the possibility that the infection was present in the population before the first imported case was reported. The report suggested that sentinel surveillance of SARS-CoV-2 in wastewater would enable adoption of immediate measures in the event of future covid-19 waves. However, the fact that the virus was found in sewage samples collected in Barcelona during March 2019 and that other reports of it being found in Brazil and Italy, cast doubts on the first cases in China being reported in early December 2019, thus saying that covid-19 originated in Wuhan, thereafter reached many other parts of the world, including here in Europe, where the first case was reported in France in late-January 2020, although there is apparently evidence that report the occurrence of cases in France in late 2019.
Scientists are speculating, simply do not know precisely the origins in place or time and are trapped in the same uncertainty as they have been with HIV since the 1970s, not exactly knowing how mutation and increased infectiousness have happened. What is being said and written by scientists but not being said openly enough, is that the SARS virus group is highly adaptable and may mutate as vaccines are developed. There have already been reported cases of people infected by the vaccine instead of becoming immune, having tested prior to vaccination and shown not to have been infected. So that tells the scientists that rapid, reactive mutation is possible. So conspiracy theories and their like aside, governments are not discussing the probable risks rather than speculative theories about how this pandemic might develop, albeit the WHO are trying to get the message across that governments should be more honest and open, whilst admitting they have been buying time with promises that may not be kept or successful. The two mutations are a warning that it is a kind of war between human beings with scientists the frontline combatants and the SARS-CoV-2 that has all the advantages on its side including the mask resisters and other people who are vulnerable to infiltrate, thus fight to survive and win from behind the frontline.
I am not a scientist, but read the outpouring of medical and science articles to take in what I can, bearing my briefings from virologists and other medical science experts at WHO HQ in Geneva on what we were going into when I worked with HIV/AIDS for a short time in 1988, although we were doing social research on victims of HIV, part of our preparation was what I wrote above about the source of HIV infection. The SARS-CoV-2 ‘story’ is very similar. I find it very frightening, not at all for myself, but for the world generally and particularly because people do not (yet) know enough to take it as seriously as it must be taken so that the doubters and ‘know betters’ realise their message is contributing to the pandemic and how it might yet develop.
Covid, the environment and climate change
Restricting and eventually cutting out entirely the drivers of climate change is probably going to help contain the emergence of new and re-emergence of existing zoonotic diseases that have been made more probable by global intensive farming, the mainly illicit international trade of exotic animals and increased intrusion into wildlife habitats. Pollution, especially non-biodegradable plastics, has also contributed to the deterioration of the conditions required for the good health of people. Those denominators also add to the likelihood of contact between human beings and zoonotic diseases that has caused one pandemic already and, we have been warned, increased the probability of this not being the last one human has to face. The enormous increase of international travel and massive growth of urbanisation have led to higher population concentrations that encourage the rapid spread of zoonoses that then pass into the human population. Those phenomena also play an important role in climate change as environmental determinants of health that, for instance, thrive as temperatures rise, thus allowing diseases once considered tropical to occur almost anywhere.
Both covid-19 and the climate crisis have exposed the fact that the poorest and most marginalised people in society, such as migrants and refugees, are always the most vulnerable to kicks in the teeth like this pandemic. When looking at climate change, the people most impacted by extremes are frequently those who have contributed the least to the root causes of the crisis. No country in the entire world is immune to preventable loss of lives caused by increasing inequalities, with all possible indicators showing that is a worsening trend.
The environment and climate change have dropped down from the top of the global agenda in part because of a general political lack of interest, the almost universal economic crisis and the need to deal with covid-19 immediately. It is now more than five years since the Paris Agreement was signed, something that gave the world, at the very least signatories to the agreement, the opportunity to focus on the benefits of protecting the environment, including the many possibilities of protecting human health that include preventing pandemics such as the one at present. Governments are planning economic recovery as soon as covid-19 is under control, if not eradicated; concerns about the environment, climate change and equity now need to be focused on a ‘green recovery’ that goes beyond commitment to the Paris Agreement. Worldwide, clean energy sources are a priority to end the vice-like grip of corporations that are economic built on and exist on the extraction of fossil fuels. Similarly, there need to be stricter controls on the things that cause environmental deterioration, including climate change. Nations need to begin making decisions to tackle each of the crises at the same time to ensure the most effective response to them and steer us toward a world in which conditions in which any other virus may appear will survive, thrive and repeat the present crisis, perhaps even be worse, will be under control.
However, half-truths, conspiracy theories and political policies are preventing us from ascertaining how the coronavirus came to infect people. We know that it is possible, perhaps even probable, that several species of bats carry genetically ancestral forms of SARS-CoV-2. Wuhan’s vast Huanan Seafood Wholesale Market is a place where both wild and domestic animals are traded, thus creating an ideal evolutionary environment for the virus to adapt to new hosts, including humans. The enforcement of laws that protect animals that are hunted or captured for food, trophies, pseudo-medicines or rituals need to be taken more seriously and wild animals sold live, as carcasses or meat traded in such markets need to be forbidden. That will, almost certainly, create a black market of those commodities that is difficult and sometimes virtually impossible to control, but at least it will reduce availability which should aid to the preservation of protected species and lessen the risk of transmission of viruses that will mutate to be a threat to humanity.
What we do not know…
Evolutionary theory foretells that pathogens transmitted from person to person frequently become less deadly over time since a disease that kills too many victims too quickly run out of hosts to infect thus die out. Although SARS-CoV-2 has been extraordinarily thus far, that may be changing. The two recent mutations in the UK and South African variant are good reason for the kind of anguish we are seeing in the scientific community struggling to stay ahead of the virus. Furthermore, there have been some alleged cases of re-infection that indicate that people have probably contracted mutant versions of the virus sufficiently different to elude their immune memory. Moreover, the detection of mutant SARS-CoV-2 viruses circulating among farmed mink in Denmark resulted in the culling of around seventeen million animals during November 2020. However, we do not know how the various mutations are affecting people sufficiently as yet, exactly how transmissible and virulent the virus is, although they both appear to be more transmissible but similarly infectious as the original virus, whether that might influence the effectiveness of vaccines, although experts tend to be of a shared view that the risk of mutation should not discourage people from being vaccinated.
What do we know about transmission?
In 2012, an entirely new disease caused by a coronavirus was identified in Saudi Arabia. That particular disease, Middle East respiratory syndrome-related coronavirus (MERS), or EMC/2012, is a species of coronavirus which infects bats, camels and human beings. It is actually far more lethal than covid-19, but also less contagious. The lesser risk of contagion is mostly because people catch MERS from camels, which most of us unlikely to do. SARS-CoV-2, on the other hand, transmits from person to person. The density of human populations and our partiality for intercontinental travel explain how covid-19 spread throughout the world within months of emerging in China. That also assumes it did originate there, until that is unequivocally proven that is the case, caution is still paramount.
There are still numerous details unknown about exactly how this virus is transmitted. As we should all know by now, the main route is via airborne particles. We also know that people are more likely to be exposed in confined indoor spaces than they are outdoors. We are still not absolutely certain how far these aerosols travel and are still finding out about such contributory factors as airflows, temperatures and the type of space where indoor transmission is most likely. Similarly, we do not yet know exactly how long it remains infectious when airborne. There is some inconclusive evidence about how great infection risk is from viral particles on surfaces, suggesting, for instance, that they may remain potentially infectious on plastic for over a week. Other views state that even if viral particles are present, surfaces are unlikely to infect someone who comes into contact with them.
At first even members of the medical community had divided opinions on whether masks work or not. We now know that wearing a mask protects both the wearer and other individuals nearby, especially indoors. Another uncharacteristic trait of covid-19 is that it can be caught from someone who has no symptoms. Early research found that up to 75% of infected people show no symptoms. One study published in December 2020 suggests that figure may be much lower. On the other hand, it is usual that when infected with other contagious diseases, for instance influenza, most people show at least some symptoms once infected. What is more, people who do not become ill as a rule transmit it at a much lower rate. People with infectious diseases also tend to self isolate, often because they are too unwell to go anywhere or of choice so as not to transmit the disease to others which gives pathogen less likelihood of being transmitted on. However, asymptomatic and pre-symptomatic transmission makes it relatively straightforward for the SARS-CoV-2 virus to be passed on, but complicated to track since testing and tracing relies on people with symptoms presenting themselves for tests.
The lockdown quandary
When news of an epidemic in Wuhan broke in January 2020 as an attempt to stop the spread of the new disease, it did not occur to the people of other countries that their lives would soon be restricted in the same way in the near future. It did not seem feasible that sooner or later an almost literal version of quarantine, originally quarantena in the old Venetian language meaning forty days, would be imposed. Quarantine has been a means of controlling the spread of infectious diseases since the 40 day long isolation of ships and people used as a measure of disease prevention, especially to combat the spread of bubonic plague in medieval Europe. Between 1348 and 1359, the so-called Black Death killed at least 30% of Europe’s population and a considerable percentage of all of Asia people. Just under a year ago, the proposition that democratically elected governments would compulsorily restrict the freedom of entire nations was implausible. By April, approaching half of the world’s population was subject to one degree of lockdown or restricted movement.
There is one significant difference between covid-19 and other infectious diseases in that the mortality rate has been relatively low. Normally no country would consider shutting down a large part of its economy during waves of seasonal influenza outbreaks, despite it causing at least half a million deaths worldwide each year. SARS-CoV-2 kills a higher percentage of people who contract it than influenza, but that tends to be because of pre-existing conditions or frailty and vulnerability that develop mostly with age, although more recently the new strains seem to be affecting far younger people, including children, with fatality numbers as yet unknown. The reason for this is not that it is worse, but that transmissibility is up to 70% higher, therefore the number of its victims far greater. Estimates originally suggested a mortality rate of approximately one in a hundred people, although there are also variable estimates in the range of 0.5% to 3.5%. It is less fatal than other viral diseases such as Ebola, which without medical intervention kills over 80% of those who catch it. As a result, politicians are still at a loss knowing what to do and lockdowns seem to be the best option so far. Worldwide, governments that acted early and positively have generally experienced lower death rates than those that such as the UK that procrastinated or Sweden that had a low rate of infection during the first wave, however it is not as straightforward as imposing lockdowns and curfews for a number of reasons.
There are people who do not believe that covid-19 is real, often conspiracy theorists whose alternative view of the people falling ill and dying is that governments are doing something akin to a cull because of overpopulation. Those people also seem to believe that the vaccination programmes are to implant microchips in us all in order to monitor and control everybody’s life. There are lockdown deniers who defy government measures, anti-mask people who have any number of reasons from the inability to breathe through to political objections and those who simply believe they know better. Those people are as likely to be vectors of the virus as resistant or invulnerable as they imagine themselves to be. Above and beyond that, there are people whose symptoms are so mild that they dismiss it as a common cold, others who carry it but remain asymptomatic and those who are totally immune to infection. Between each of these variants as yet neither scientists nor governments have been able to work out which strategies work best and will not be until well after this pandemic is over, even then conceding that it may be with us permanently and that controls similar to annual influenza controls are the only option.
The quandary is actually exacerbated by using models to predict what percentage of the population is expected to fall ill or die if a lockdown is not imposed. Policymakers are forced to act on that information, knowing that those models are not necessarily precise because transmission of the virus is unpredictable so that there will be consequences anyway. Thus far, many governments are responding responsibly whilst others including the USA have only just begun to take the severity of the pandemic seriously. It now remains to be seen whether or not vaccines will be as effective as hoped, have long term effect rather than the seasonal efficacy of influenza jabs or whether mutations will defeat the objective of vaccinations programmes.
Here I am faced with the almost moral dilemma of asking whether or not I am adding to the excessive information being more or less thrown as people that have holes and inaccuracies with the possibility of innocently or maliciously included conspiracy theories and political finger pointing. I have attempted to rely on sources that can be substantiated rather than on media reports that often carry ‘yesterday’s’ information that has been overhauled and augmented to newer and better. To my own advantage I have a long research career that has taught me to always allow a bit of space for the benefit of doubt unless something is so indisputably proven that there is no reason for misgivings of any kind. For that reason I have not allowed myself to use any ‘perhaps’ sources where my own knowledge was not sufficient.
Historically, epidemics and pandemics have usually occurred with enormous holes in the knowledge about their origins and transmission. As it stands it is true again now. We broadly speaking regard Wuhan as the source and bats as the origin of SARS-CoV-2, but some doubts remain. Then there is the question on how, whether or not the location of the source is right, worldwide transmission of this virus has happened so rapidly. Academic journals have already published thousands of articles and reports on the covid-19 pandemic. One would need to read and process a few hundred of those articles every day to stay abreast of knowledge and actions to prevent and even eliminate the disease. The biological differences of SARS-CoV-2 to other coronaviruses, indeed viruses in general, complicate even scientific progress. Thus, there is no unanimity in the scientific community that makes it easier for misinformation and conspiracies to circulate, consequently making it more difficult for governments to formulate public health measures for either immediate or longer term action to deal with the pandemic. Thus rumours and conspiracy theories have led to large numbers of so-called anti-vaxxers and other resisters who governments have failed to communicate what and why they are employing methods like lockdowns effectively to people. The outcome is that the public have become selective about the information they believe and suspicious of political declarations, even when they are backed up by sound scientific statements. Whilst vaccines become available and vaccination programmes are started, the public must still deal with risk and uncertainty in order to prevail over this very extraordinary pandemic. Because of that, the overload of information effectively thrown at people, often through media that either present what they consider to be facts differently or contradict each other, needs to be brought to rein, thus helping rather than hindering how this virus is dealt with.
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