The truth about COVID: Greatest global risk is rapid spread in low-income nations with few resources to prevent explosive growth of infections, and many new variants. Future of health care keynote speaker

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12th February 2020

We have to fix global risks from new viruses

Repeated warnings about major risks from new viruses 

At a time of panic about the new Coronavirus SARS-CoV-2, here is a common sense view. Firstly, there is nothing new about mutant viruses causing major disruption, or even pandemics.  The real issue is lack of investment in developing antivirals - which is why our world is still so astonishingly vulnerable, with very little to offer people with viral infections, compared to bacterial infections.

Since 1987 I have been predicting the great vulnerability of our world to pandemics caused by new mutant viruses, or mutations of existing ones like SARS-CoV-2: in my book The Truth about AIDS, in Futurewise published in 1998, and in The Future of Almost Everything published in 2015/2019.

I am writing this as a physician and trends analyst who has been involved in the fight against HIV (another mutant virus) for over three decades, and as a Futurist, advising governments and corporations around the world on a wide range of global trends including the future of health care.

The reason is that new virus types appear every year, and we lack antiviral drugs to combat them.  Only some of these are coronaviruses.

Indeed, the most effective antivirals today are less powerful than penicillin was against many types of bacteria when first discovered in the 1940s.

Vaccines can also take a very long time to develop against coronaviruses and other pathogenic viruses, and may only be partially effective.

For example, don't expect an effective, safe, widely available vaccine against this coronavirus SARS-CoV-2 for 12-18 months.

Years ago I wrote: "With around 7 billion people alive today, there is a small risk of viral mutation every time a single person is infected with any existing viral type, made easier by dense urbanisation in many countries, dramatic growth in international travel, and the lack of an antiviral equivalent to penicillin. Conditions have been perfectly set for some time for just such outbreaks as Swine Flu or Sars. We should therefore expect more to follow - less or more dangerous than Swine Flu."

This has also been the position of the World Health Organisation for over two decades.

Longer term global challenge from new viruses and new illnesses like COVID-19

Whatever happens regarding the current situation which will be very difficult for governments to control, the longer term global challenge therefore is that coronavirus 2019-nCoV is just one of a large number of totally new agents emerging each year, often in China, the vast majority of which are relatively harmless causing combinations of aches, pains, fevers, rashes, gut problems and other symptoms.

A small proportion of such new viruses are so lethal that they typically kill their victims before there is much opportunity for transmission, so infections tend to die out rapidly.

But the most dangerous potentially to the global community are new viruses which have longer incubation periods, and are less likely to kill. Coronavirus SARS-COV-2 is much less lethal to an average infected person than SARS was in 2003, but has already spread far more widely, does appear to be more infectious, and has the potential to cause a global pandemic.

Many of these new viruses typically emerge in South East Asia, in nations like China, having jumped from animals into humans, sometimes with a mutation at the same time.  

Just one such new virus was of course HIV, which to date has killed over 40 million with illnesses related to AIDS.

Fortunately we have effective antivirals now against that particular virus, after years of intensive research, but it remains a major global health risk, with just under 2 million new infections a years, and many deaths linked to AIDS.

How Coronavirus SARS-CoV-2 may mutate further

A huge uncertainty is how this new coronavirus will evolve. All flu-type viruses tend to go on mutating - they can become more or less dangerous and more or less infectious.  

The good news is that a very common trend is for new viruses like SARS-CoV-2 to become less lethal, as they pass through one person to another and across neighbourhoods.

But sometimes a new virus can infect someone who is also carrying ordinary flu, and their cells get muddled about which virus to make, so that a new combination of genes happens.  

Such an event could change the virus radically in behaviour, however SARS-CoV-2  does seem relatively stable compared to ordinary flu or the common cold.

We need to know how SARS-CoV-2 is transmitted

There's a huge amount of research to do into how this particular coronavirus spreads.  It's really important in understanding what the real risks are.  In any viral condition, you can form a list of potential routes of infection, but the key is knowing which one or two cause 90-95% of all cases.

SARS-CoV-2 appears to spread mainly by significant exposure to the virus through coughing and sneezing to those within a metre or two, but SARS in 2003 did spread to some people by surface contamination, causing hand contamination, then transferred to nose / mouth.  

One research paper suggests that coronavirus may be excreted in faeces.  But it appears that most people catching SARS-CoV-2 have been in close proximity for some time to someone who is coughing or sneezing, or who is otherwise unwell.

Ordinary flu is also a major killer

We also need to remember that normal flu kills 50,000 a year in the US, and around 75,000 across the EU, mainly older people, particularly if frail with other serious conditions.  

Doctors are used to seeing death rates three or four times normal every deacade or two, so US death rates from 2019-nCoV of - say - 150,000 would not be that far from normal year on year variations.  

I am not saying that is what is going to happen, only that we need to see things in proportion.

Vital to know %  infected with no illness or very mild symptoms

Common signs of SARS-CoV-2 infection are fever, cough, sneezing, shortness of breath and breathing difficulties - all of course extremely common with other viruses, but are the classic pattern seen in COVID-19 illness.

Testing is complicated, time-consuming, costly and requires highly trained people in specialist centres - which can easily be overwhelmed. That is why doctors shifted in China to making a presumptive diagnosis of COVID-19 in any patient  with the above symptoms + classic chest X-Ray appearances, which can include multiple shadows on the lung, ground glass appearance and many other factors.  

It's not a perfect diagnostic system, but it's rapid, gives the right answer a lot of the time in people with cough and fever who are suspected of having SARS-CoV-2 infection, and enables much faster contact tracing / control / treatment.

However, it seems that a significant number of people are becoming infected, who don't get anything more than very mild symptoms, maybe none at all.  

We know that the risk is more than ten times greater for someone over the age of 80 with multiple medical problems than for a healthy 30 year old, and serious illness is very unusual following infection in children.

On the one hand, very mild illness in most of those infected will make spread far harder to track and prevent.

But on the other hand, it means that reported death rates as a percentage of total infected are almost certainly far too high, because we are missing most of these other milder cases.

Every person who recovers is of course carrying antibodies against SARS-CoV-2, and unravelling how the body responds will lead to all kinds of treatments.

To be certain of all this, we need to be testing large numbers of people who are completely well, to see if they have any evidence of previous mild infection.

And that requires far more laboratory capacity than testing only those who are acutely sick, and their close contacts.

Strict quarantine and contact tracing is absolutely vital in early stages

Some may argue that draconian measures to limit spread of SARS-CoV-2 will not be enough to prevent a global pandemic.  This may turn out to be correct - at the time of writing (24 Feb 2020) we just don't know yet.

But even if that does turn out to be the case, it is critically important to slow down spread in early stages of any new viral disease as much as practically possible for several reasons.  

Firstly, to give time for experts to study the first cases, learn more about how it spreads, how dangerous it really is, risk factors for getting ill, and the best methods of treatment.

Secondly, it gives time to prepare potentially very large scale responses, educate communities about simple ways to reduce risk of infection, ramp up testing facilities, manufacture supplies, train health care workers, mobilise communities and create additional treatment facilities.  

Thirdly, time for warmer weather to help reduce spread. In Spring or Summer, such viruses don't spread as well, and there is less pressure on health services from other illnesses like flu.  Most people live in the Northern Hemisphere or close to the equator.

Fourthly, time for wealthy nations to assist emerging nations with health messaging, community mobilisation, testing, quarantine, treatment.

Fithly, slowing down speed of spread will mean that health services will be less overwhelmed than if all those who are ever likely to become infected, do so over a relatively short period.

However, it is also true that the longer it takes for a major epidemic or a pandemic to burn itself out, the longer the economic disruption can be, and that means governments may have very difficult decisions to make.

For example, about when to tighten up draconian measures such as shutting a nation's schools, universities, shopping centres, leisure centres, churches and so on, and went to relax those same regulations if it seems that a new virus has already spread so widely that such measures are no longer likely to have significant impact.

China has shown importance of centralised government powers and rapid action

For all these reasons, we should commend and learn from China's gigantic health care response to SARS-CoV-2, as a national emergency.

While other nations have had more time to prepare, this coronavirus was spreading rapidly in China before many realised what was happening, because the symptoms are those of many other viruses.

The truth is that very few other nations of the world have government powers and strength of organisation to respond in such rapid and comprehensive ways. 

We can expect other nations to impose strong measures to isolate communities and restrict large gatherings in affected areas, in earlier stages, when such measures are likely to have greatest impact

Lessons from SARS chaos in 2003

The first SARS virus spread rapidly in 2003 but there were only 862 deaths and only around 8600 cases. 

Yet China faced a national crisis with thousands fleeing cities like Beijing, possibly carrying infection with them across many SARS-free areas. Normal life in some places ceased.

After much delay the government introduce with draconian measures including quarantine for entire buildings, thousands of workers, entire hospitals, severe limitations on travel, cancellation of public holidays, huge fines for spreading false rumours and so on.  

We have seen major disruptions since with other new viruses, for example in Mexico.  This time, with SARS-CoV-2, the Chinese government have acted at great speed and with huge responses.

Our world was very fortunate with SARS in 2003 that there were no cases in nations such as DR Congo or Zimbabwe, nations with very few health care resources, and weak government structures, compared to China, which is highly organised, efficient and centrally controlled.  

A single superspreader on one plane in such a low-income nation, would have been enough to ensure that Sars became a semi-permanent health care problem across the world.

Lessons from Spanish Flu in 1918-1920

The Spanish Flu pandemic shortly after the end of the First World War spread globally in a few months, in an age of horse and carts, steam ships and rail.  

Historians may argue about impact but the death toll was probably greater than 30 million and it was caused by H1N1 virus, similar to Swine Flu virus in 2009.  The global population was far smaller then, and transport very slow compare to today.

That is why it is right that every nation continues to take national responses to SARS-CoV-2 seriously.

Expect more mutant viruses - urgent need for better antivirals 

As I have often said in the past, all this underlines the urgent need to develop effective antiviral medication.

It is shocking that 60 years after the discovery of penicillin we still do not have a single antiviral that is as effective as the earliest antibiotics.

When we do, we will have a cure for common cold, flu, polio, smallpox, viral meningitis and viral pneumonia - amongst many other conditions. Genetic engineering may be a key weapon in vaccine development.

Reducing personal risk

In the meantime, all those potentially at risk can take simple steps to stay well - helping protect you from a host of other flu-like viruses, as well as ordinary coughs and colds at the same time. 

The virus cannot cross your intact skin - but moist membranes are vulnerable eg nose, mouth, eyes (probably).

That means washing hands regularly with soap, not touching your face, and using disinfectant hand gel in addition if you wish.  

And to state the obvious, don't spend time close up to someone who might be a carrier, particularly if they have a fever, are coughing or sneezing.

World Health Organsation Coronavirus 2019-nCoV update and infection control guidelines

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