Pandemic COVID-19: What do we have to fear?

This post is by Jennifer Cole PhD, a full-time Research Fellow at Royal Holloway, University of London. She is an Associate Fellow at the Royal United Institute for Defence and Security Studies, a UK-based policy think tank, where she ran the Resilience and Emergency Planning programme until 2018. She has also worked with UK and international government agencies on policy planning around the response to serious infectious disease outbreaks. Find her Reddit AMA on the COVID-19 pandemic here.

When people use the word ‘pandemic’ it tends to incite fear. It conjures up pictures of widespread death and societal collapse, the Hollywood movie version of what would happen and how the world would(n’t) cope with a new, unknown disease. History lessons of the Plague of Athens, the Black Death and, more recently, Spanish Flu bubble to the surface of collective and cultural memory. Millions of deaths. Bodies piling up in the streets. Society breaking down. 

But take a deep breath (through an N95 respirator mask if you want to be careful), step back and try not to panic. Even if the worst case prediction of case fatality ratescurrently running at around 2% turn out to be true – and it is increasingly looking as if this is a high-end estimate that doesn’t take into account the many cases that go unreported because symptoms are mild – there is no reason to think that this will equate to societal and economic collapse; the 1918-19 influenza outbreak had a similar CFR but didn’t, even in a world already economically depleted by WWI . There are currently 7.6 billion people in the world: even 2% less than that is still a lot more than 7 billion. The world won’t lose all its doctors, or airline pilots, or software developers, or rap artists. 

Pandemics and societal change

Pandemics with much higher CFRs – 30-60% – were needed to bring about real societal change. The UK’s medieval system of serfdom – essentially slavery to the landowners – was broken by a shortage of workers, meaning those who were available were able to negotiate better terms for their labour. Gandhi first rose to prominence by helping Indian clothworkers to demand better working conditions following similar labour shortages that resulted from an outbreak of Bubonic Plague in India in the early 20th century.

Society did anything but descend into chaos on either occasion: the affected communities came out stronger and more just. Neither is collapse likely with SARS-Cov2, the virus responsible for the COVID-19 outbreak. This isn’t to play down the situation. It isn’t to belittle the virus as ‘just a cold’ or to not care about the people who have died and will still die. But it is a call to keep things in perspective, to guard against panic, and to consider what part everyone has to play in responding to events over the coming weeks. 

Vector graphic showing COVID-19 viruses. They appear to be spreading, pandemic-like across the image

What is a pandemic, and are all pandemics deadly?

So is SARS-Cov2 a disaster? A death sentence for the world? The end of civilisation as we know it? The evidence is increasingly saying ‘no’. Pandemics have, in the past, been all those things but at the same time, all ‘pandemic’ means in literal terms – ‘pan (all) and demos (people)’ – is ‘everywhere in the world’. It denotes the geographic range of the spread, not severity of the disease, but tends to be interpreted by lay audiences as the latter only. This is precisely why the WHO revised how they used the term following the 2009-10 H1NI ‘Swine Flu’ pandemic: when the virus responsible turned out to cause only mild disease in most cases, they were criticised for over-reacting and of encouraging countries to ramp up unnecessary countermeasures.

The media prefer to hear about PHEICs – Public Health Emergencies of International Concern – because they’re easier to make headlines out of. Emergency! Concern! even though PHEICs may not be everywhere or much of a threat to most people other than the ones whose job it is to deal with them. Anyone remember the Polio PHIEC of 2014? It didn’t spark sensational headlines because the world has a vaccine. The fact that the vaccination programme had broken down in war-torn Syria, putting thousands of Syrian children at risk – but no-one else – wasn’t a good enough story.

Ebola, which was happening at the same time, got much more attention. There was more of a threat from a disease that didn’t have a vaccine – although, as it turned out, even that threat was reasonably easily mitigated by any quarter-decent healthcare system. A few years before, Swine Flu had made the headlines when people who don’t usually die if they catch influenza thought they might, but everyone then lost interest when they realised that this wasn’t the case. At the same time, the papers forgot that more than 600,000 people die each year from normal seasonal fluup to 10,000 in the UK alone. This is also pandemic, but no-one really worries too much about it.

So how does all this relate to coronavirus SARS-CoV2? Should we be scared that (a) it’s a PHEIC and (b) that it may or not be ‘officially’ a pandemic depending on whose classification is used and how that classification is made? 

A COVID-19 pandemic: should we panic now?

The key to how scared someone should be of a disease is, of course, how likely they are to be affected by it. Primarily, how likely they are to die if they catch it. This, in turn, depends on a number of factors, including, but not limited to: [1] how susceptible they are to catching the disease, [2] how able to naturally (without any medical help) fight it off if they are infected, [3] how much, and what, medical help is available if they can’t fight it off without medical intervention, [4] how measures including quarantine and vaccination offer protection [5] and what can be done to avoid catching it, which includes everything from handwashing, using a face mask, to self-isolating and quarantine. PHEICs drive international cooperation. Pandemics encourage rapid research and vaccine development, bring greater and more immediate investment, galvanise the research community to work together and lead to greater understanding of not only the disease itself, but of how best to organise healthcare systems and response. Not all of it is bad news.

Vector graphic showing a network of people wearing face masks, surrounding one person who is not wearing a mask and who appears to be infected with coronavirus, the disease responsible for the COVID-19 pandemic.

So, let’s deal with each of the factors mentioned above in turn:

1. How likely am I to get COVID-19?

In the case of SARS-Cov2, the current planning assumptions are still that everyone is susceptible to catching it. That no-one has any innate immunity (obtained from having caught it once before, when they may have been younger and fitter and more able to fight it off). There may be little genetic immunity (which can exist within a society because people who are less able to fight it off don’t survive to breed) because it hasn’t been around long enough for this selective pressure to come into play.

Equally, however, there may be – some people were naturally immune to Ebola because they carried an allele known as CCR5 Delta-32– which also offers protection against HIV. General virus-fighting biology may be working behind the scenes but it takes a long time for scientists to figure this out – with Ebola, it was deduced from analysing family members who had all been exposed but not all of them became infected – but things have so far been happening very, very quickly with SARS-Cov2; too quickly for such analyses to be made.

The cruise ships are the best microcosm we have to deduce how many people who have clearly been at risk don’t become infected. More time will be needed to develop a clearer picture on this but out of 3711 crew and passengers, only around one in five seems to have contracted the disease. 

2. How serious are the symptoms?

A second factor in how badly the virus will affect society is how likely the average person who contracts it will be to require hospital treatment. This is particularly difficult to calculate from early cases as mild and asymptomatic ones will not be recorded. Only the severe cases tend to be diagnosed – possibly only those who go on to need hospitalisation – show up in the figures. It seems that many people either didn’t realise they were infected or had such mild symptoms they didn’t go to a doctor. It was indeed, ‘just a cold’ for them. Here, again, the cruise ships will provide some of the most accurate numbers available, as will contact-tracing relatives of known cases and people who are known to be at risk of exposure.

Normally, healthy people aren’t tested for cold or flu viruses or recorded in medical records, and thus severity and case fatality rates tend to be overestimated at first, and drop as more figures become available. Now that significant numbers of people are being tested – whether they’re ill or not, and whether they’re mildly or significantly ill – the real picture will become clearer, as will info on what types of people are more likely to be severely ill than mildly ill: the very elderly, those with underlying health conditions, heavy smokers etc. Once demographics have been established, people outside of those categories can worry a bit less. Early indications so far suggest that the risk of dying if one contracts the virus is around 14% for people over 80, but only 0.2% for those under 40. 

3. Can we treat COVID-19?

Medical help is available, and paints a reasonably optimistic picture. Dealing severe respiratory conditions is a staple of hospital operations: there’s lots of equipment and trained nurses and doctors. If you end up in hospital, they know what to do. The real challenge with SARS-Cov2 is that there will be more people than usual in hospital at the same time. Mostly old, already ill with other conditions, or immunocompromised people – but still more. Remember the accusations that Swine Flu was a bit of crying wolf? The NHS doesn’t – the UK’s healthcare sector only barely coped. Still, it did – due to years of planning, exercising and preparation. People died, but not that many more than in an average flu season.

The biggest concern with SARS-Cov2 is that high numbers of severe cases – quantity rather than quality of disease – will result in not enough of this medical help to go round. This is probably the biggest real concern in the current situation. It’s why one of China’s first actions was to build the massive temporary hospitals, why the US’s FEMA is sending out letters requisitioning hotel beds, and why in most countries, emergency plans will be kicking in to do the same and to see what other things hospital beds are used for – such as routine hip replacements, for example – can be postponed for a few months.

In the meantime, quarantines, social distancing and encouraged self-isolation will help to protect these elderly and vulnerable members of the population, as well as those who could probably fight it off alone. This doesn’t mean that quarantines, lockdowns and self-isolation is an over- or knee-jerk reaction – but rather than only benefitting the quarantined individual, they buy time: to understand the virus better, to learn how to deal with it, to calculate more accurate figures for how infectious it is and the case fatality rate it causes, and how to prevent it. 

4. Can we vaccinate against COVID-19?

One main advantage of quarantines, lockdowns and curfews is that they buy time: for healthcare professionals and scientists to figure out how best to deal with the disease and, ideally, they buy time in which vaccines can be developed and trialled. Even if and when it’s completely understood that containment measures cannot keep a disease from spreading and becoming pandemic for ever, it is still worth slowing that spread down – as much as possible, for as long as possible. This is the best response for society at a mass level – but has to be weighed against the damage quarantines may cause, such as panicking people, and damaging the economy.

The alternative is to let the virus run and take the consequences – potentially sacrificing the elderly and vulnerable for whom there may not be enough healthcare.  It would take a very, very brave politician to make that call. The politically safer (and more human) option is to keep plugging away with the quarantines even when you know they will ultimately fail to contain the spread. 

5. How do I avoid catching it in a pandemic?

At a societal level, however, there is still much we can do. Human behaviour is an important factor in disease spread as the characteristics of the pathogen itself and everything from basic handwashing, not coughing on your neighbours, working from home if possible and shopping online for groceries, will have a significant impact on whether you personally catch the disease and whether the chains of infection across the world can be broken. Emergency planning scenarios tend not to like to focus so much on human factors, as they’re harder to control, but once factored in, they make the whole situation much, much less scary. 

Vector graphic of a bar of soap overlaid on a blue background that looks like splashing water. Washing your hands with soap is one of the easiest ways to keep yourself safe in this pandemic.
Washing your hands with soap is one of the most effective ways to sanitise them. Hand sanitiser gel will also work if soap isn’t available – it’s not just effective on bacteria!

How prepared are we for a pandemic?

Knowing the amount of planning that goes into how the world will deal with a situation like SARS-Cov2 can also provide reassurance that society is far from collapse. Not just in terms of how the medical sector will deal with so many additional hospitalisations, but how supply chains will be kept running, how pharmaceutical production can be ramped up quickly, and many, many other aspects.

The vast majority of these plans have been publicly available for years but the irony is, the public mostly ignores them and even sneers at them until the crisis hits. But they’re there, and people are working behind the scenes right now – just as they always are – to make sure that they hold up as well as possible under very trying circumstances. A massive help to how well they can operate is making sure the public doesn’t panic – that people take avoidance measures where necessary but don’t get overly worried about what they can’t change. Society will only break down if society allows it to. 

So we’ll get through this pandemic?

It is important to keep things in perspective. ‘Pandemic’ refers to the number of cases and the number of countries a disease is spreading freely in, not its severity. If and when SARS-Cov2 becomes pandemic, this doesn’t mean it’s more or less infectious/serious/scary than it was last week. It means that countries and their healthcare sectors are more alert to it, more likely to reach for, assess and amend where necessary their own emergency plans to deal with it. This includes how they will cope with more hospitalizations, what additional supplies they need to start drawing in and how they reorganise to manage something beyond business as usual. Swine flu is recent enough that plans have been tested within living memory, and they did hold up.

Pandemics have the greatest effect at a societal level

For those still feeling that the best response is to panic: keep in perspective the difference between risks to individuals and risks to society. The longer outbreaks go on, the more information emerges about them. The more SARS-Cov2 cases are understood, and the more information and understanding is gained about asymptomatic or very mildly symptomatic cases, the more it looks as if, on an individual level, the virus may not be too much worse than a typical seasonal flu season for the majority of people under 80.

At population level, this is still a significant challenge because – unlike the viruses that circulate during a typical flu season – no one has any immunity to SARS-Cov2, so overall there will be many more cases. The people least likely to be able to fight it off – the elderly – won’t be protected by residual immunity from other viruses that were similar enough to the current one to help. In the 2009 Swine Flu epidemic, residual immunity to the Asian flu(s) of the late 50s and 60s meant that the elderly had some protection. That’s not there this time. But, if you aren’t elderly, don’t have an underlying immune condition and seek treatment early, it is looking increasingly as though you are likely to survive infection, without needing hospital treatment..

The picture is somewhat different for those who work in the health system, who are likely to face significantly increased workloads. But preparedness plans (all publicly available online) are in place and the doctors who know about them tend to be playing down the dangers

Quarantines are a good thing

It’s also important to acknowledge that the quarantines and lockdowns in place across the world look dramatic on TV but are there primarily to slow down the spread of virus, which has two main advantages:

1.     If the spread is slower, an outbreak in one area might be more or less over before another one starts. Resources can be moved around and go further if the entire world doesn’t have to deal with all cases there will ever be at once. In particular, once an outbreak has passed through one region, it tends to leave behind recovered and immune survivors who can help those who come after them. 

2.     Secondly, the slower the spread goes, the more time there is for vaccine development, to protect those in regions not yet affected. The world’s vaccine developers are working round the clock to make sure this happens: a vaccine may be ready for early human trials in April [30]. 

The scenario presented above isn’t the sensationalised doom-mongering that makes the best tabloid headines. Nor is it looking at the challenge through rose-tinted glasses. Panic never solved anything; the best approach to any crisis is to be well-informed, well-prepared and ready to meet it head on. The young(ish) and generally healthy will mostly survive. By doing what we can to avoid catching the virus and passing it on, everyone can help to protect those who are older and less generally healthy.  By aiming to be part of the solution, not the problem, we all have has a part to play in keeping society in the best health possible over the coming weeks.