COVID-19

The lessons of COVID-19

In my latest podcast episode for Dispatch 7, I talk about what we’ve learned from the COVID-19 pandemic. Why did some developed countries respond more poorly than developing nations? What lessons does history teach us about the value of quarantine? And what is a One World approach to global health?

Shawn Smallman

Why was the 1918 flu pandemic more frightening than COVID-19?

The Spanish Influenza. Chart showing mortality from the 1918 influenza pandemic in the US and Europe. Wikipedia commons.

According to the CDC, as of September 10, 2021, 652,480 Americans had died of COVID-19. This is nearly as many as the perhaps 675,000 Americans who died in the 1918 flu pandemic. But there seems to be much less fear of COVID-19 now than there was of the influenza pandemic then, at least in some parts of the United States. Why?

Of course, the first point to make is that there was certainly denial and minimizing in the United States in 1918, which people used to justify holding everything from war-bond rallies to weddings. Still, after the terrible month of November 1918 this declined. Is the difference between then and now in part that we live in social media bubbles? I think that there is some truth to this, but there are a few factors that explain the different attitude that many people had towards influenza then.

In 1918, there was a “W” shaped mortality curve, as most people who died were infants, young adults and the elderly. Before the arrival of the delta variant, there was a perception that those people most at risk of COVID-19 were over 65, and perhaps their deaths were less shocking. In contrast, younger people felt relatively safe. In 1918 it was people in the prime of their life who were dying, as well as their children. This made people feel more vulnerable.

Today, people typically die in the hospital. In 1918, if you lived in a rural area -as did most of the population- a trip to the hospital would take time and might not be easy. More people were cared for –and died– at home. I think that this meant that people saw the results of outbreak much more directly. Today, the ill vanish into hospitals. Their suffering leaves nurses and doctors traumatized, but isn’t visible in the same way that the 1918 pandemic was, when family members and neighbors would see the bodies taken out the front door.

There were three distinct waves to the 1918 influenza pandemic. But the fall 1918 wave had a much higher peak in the death rate. Of course, the spring 1918 influenza outbreak was terrible in some places such as the military camps in Kansas. But by November 1918 the number of deaths was so crushing that denial was no longer an option in many communities. People were too busy taking care of their neighbors; everyone could watch the gravediggers. COVID-19 has been more spread out, which has changed how people have talked about it.

The US population was much smaller in 1918 than now, at just over 103 million people, versus 328.2 million. So although the total numbers of deaths are similar, the death rate was roughly three times higher a century ago. People saw much more death during the 1918 pandemic.

I also wonder if people didn’t have a different attitude towards medicine. The 1918 pandemic took place before most childhood vaccines, antibiotics, and modern therapies. People had more limited expectations for what a doctor might do. Now, it might be that many people expect that if they go to the hospital they will be saved, because they have often seen sick family members or friends healed in a hospital. I can’t prove this, but I suspect some COVID-19 patients are shocked when they find out that they will die. In 1918, people respected and valued doctors, but the life expectancy for men was 36.6 years, and 42.2 for women. People didn’t feel as invulnerable -and didn’t assume that the hospital would save them- because they were more familiar with death. In 1917 -the year before the pandemic- the second most common cause of death in the US was pneumonia and influenza.

Of course, in 1918 people relied heavily on newspapers and the government for information, whereas now people turn to social media. But I think that people were more familiar with infectious illness in 1918, and experienced the pandemic in a different way than with COVID-19. This difference perhaps helps to explain why in many states people seem to be much less afraid of COVID-19 than their great-grandparents were during the 1918 pandemic.

Shawn Smallman

Historical photo of the 1918 Spanish influenza ward at Camp Funston, Kansas, showing the many patients ill with the flu- U.S. Army photographer

New light on the mystery of COVID-19’s origins

Photo by Vladimir Fedotov on Unsplash

Over the last year and half there has been a bitter debate over the origins of COVID-19, specifically whether it began as a spill-over event from a wild animal to humans (the natural origins hypothesis) or because of an accident at a science facility (the lab leak hypothesis). We now have some new information to shed light on this debate. We’re all familiar with Freedom of Information Requests in the United States. These often don’t lead to the release of information, because in practice individuals or the media often have to take the government to court to get this information. That’s exactly what the Intercept did, and the results were worth it. The Intercept received 900 pages of documents regarding two grants, which they discuss in an article, written by Sharon Lerner and Mara Hvistendahl, “New Details Emerge about Coronavirus research at Chinese Lab.”

One of the key issues with the lab leak hypothesis was whether work with bat coronaviruses was being done at a lab in Wuhan, including gain of function work. Yes, yes it was, although there is a significant debate about what constitutes gain of function work. And it turns out the documents that prove this come from a U.S. based health organization called Ecohealth Alliance, which used federal funds to finance this research. This has been suspected for some time, but we didn’t have much information to clarify the details of this work. Now we know that a US researcher, Peter Daszak, had a grant to screen bats for novel coronaviruses. This in and of itself might be valuable research, if undertaken under adequate safety conditions. The work was done at the Wuhan University Center for Animal Experiment, not The Wuhan Institute of Virology, which has received the most attention in the press. And there are concerns about the kind of work researchers were doing with bat coronaviruses. According to Richard Ebright, they were doing more than just infecting ordinary mice with this virus: “The viruses that they constructed were tested for their ability to infect mice that were engineered to display human type receptors on their cell(s)’.” According to this article, the grant to do this work ran from 2014 to 2019.

I was initially skeptical that the work of the Ecohealth Alliance could have contributed in any way to a lab leak. But there does seem to have been a contradiction of interests in the early investigation of COVID-19’s emergence. Peter Daszak was one of the scientists who signed a letter to the Lancet on February 19, 2020 in which scientists denounced as conspiracy theories the idea that a lab leak began the pandemic. He also was part of the WHO’s inquiry commission that went to China in January 2021 to try to uncover the origins of the virus. Since he was involved with work at question in China, his presence would seem to undermine the potential impartiality of this investigation. More recently, he has withdrawn from at least one effort to investigate the pandemic’s origins: “Dr Peter Daszak, president of the US-based EcoHealth Alliance, has “recused himself” from the inquiry by leading medical journal the Lancet after he failed to declare ties to the Wuhan Laboratory of Virology, which was conducting research into coronavirus in bats.” The point is that the early investigation of the lab leak theory may not have been fully impartial, and key evidence was missing.

Some scientists say that what these newly-revealed documents demonstrate is shocking. As Richard H. Ebright (Board of Governors Professor of Chemistry and Chemical Biology at Rutgers University) has said, the “materials further reveal that one of the resulting novel, laboratory-generated SARS-related coronaviruses –one not been (sic.) previously disclosed publicly– was more pathogenic to humanized mice than the starting virus from which it was constructed. . .”

We need to have better information on multiple questions: did miners in southern China (specifically the Mojiang mine in Yunnan) suffer from an acute pneumonia similar to COVID-19 in 2012? Was this pneumonia caused by a coronavirus which was then brought to a laboratory in Wuhan for further research? Was gain of function work with coronaviruses done at one or more labs in Wuhan, and what -precisely- were the biosafety practices and procedures? Was there a major move at one of these labs in December 2019, and what were the safety practices at the lab during the move, particularly for bats and other animals, as well as coronavirus samples? Were any employees of these labs ill with a pneumonia-like illness in November/early December 2019? Is it true that one U.S. based scientist, Ian Lipkin of Columbia University, heard of the outbreak on December 15, 2019, well before China revealed the outbreak to the WHO? If so, does this mean that the Chinese authorities knew of the outbreak, but did not share this information in a timely fashion, so that the world could try to prevent the disease from escaping China? Increasingly, the answer to most of these questions would seem to be a plausible yes.

As Alina Chan (a postdoctoral fellow at the Broad Institute) points out, COVID-19 wouldn’t be the only example of a leak at a facility in China causing a significant disease outbreak. Elizabeth Shim’s article on this outbreak, “Brucellosis cases in China exceed 10,000 after vaccine factory accident,” is well worth reading. So we know that such accidents happen, including in China, at the same moment that COVID-19 itself emerged.

While we cannot yet know the truth, as others have said, it seems a strange coincidence that the outbreak began in the same city in China where -as these documents from the Intercept show- work was being done on bat coronaviruses. And how can we trust any denials, when much of the information that we had was not originally released by EcoHealth Alliance or the Chinese government, but rather by a small band of digital detectives scouring the web, as well as journalists, such as those at the Intercept?

Of course the lab leak hypothesis is not proven. Most epidemics begin with a natural cross-over event from animals to humans. But the irony is that if, indeed, the virus emerged from a lab leak, it not only did so unintentionally, but also because scientists were trying to study coronaviruses to avoid and prevent epidemics. If the lab leak hypothesis is correct, I can’t help but feel empathy for the scientists and funding agencies, which must have been horrified as they realized what they might have unleashed. But it is long past time for transparency, so that everyone can understand the data and evidence regarding whether a lab-leak in Wuhan, China began this pandemic.

If you want to see the documents (two grant applications) themselves, Mara Hvistendahl (@Mara Hvistendahl) has Tweeted the links, which you can for yourself here. The first one is the key document:

“Understanding the Risk of Bat Coronavirus Emergence”
https://t.co/FrOP7tSs4D

“Understanding Risk of Zoonotic Virus Emergence in Emerging Infectious Disease Hotspots of Southeast Asia”
https://t.co/YDmfbcHcoN https://twitter.com/marahvistendahl/status/1435180983754579973?s=27

I want to thank both Sharon Lerner and Mara Hvistendahl for their careful investigative reporting, and making these documents public.

Shawn Smallman, 2021

The strange, sad story of Ivermectin

Photo by Thomas M. Evans on Unsplash

Ivermectin is an old medicine used to treat parasitic infections in humans, for everything from river blindness to scabies. It is better known, perhaps, as a deworming medication that farmers and pet owners use to treat everything from cattle to dogs. The medicine has been used around the globe for 40 years. With the onset of COVID-19 -as people were desperate for some treatment, they have seized on different medications as a possible cure-all. The first was hydroxychloroquine, a medication commonly used to treat malaria. I first heard about this medicine from a neighbor, who told me that her spouse was obsessed with it. This was in the spring of 2020, when people in Boston and Cambridge were watching a tent being set up outside of of Massachusetts General Hospital to treat COVID-19 patients. People were desperate for a treatment. After being trumpeted by the Presidents of the United States and Brazil, a series of well-designed scientific studies showed that the medicine had no clear advantages while holding significant risks. As it fell out favor, people then turned to Ivermectin.

Of course, Ivermectin has been shown to have some antiviral properties. But so have many other medications. The question was- what was the evidence that it was useful against COVID-19? Very quickly my timeline on Twitter was filled with people talking about Ivermectin. The most common comment was perhaps that big pharmaceutical companies were hiding their knowledge about Ivermectin because it was off-patent and cheap. Dr. John Campbell -who has an excellent YouTube channel with daily updates on the COVID-19 pandemic- began to highlight Ivermectin as a potential treatment. An Indian state encouraged its use. Desperate people began to go to farmer’s Co-ops to obtain medicine intended for cattle for their use. Countries put Ivermectin into their national guidelines for the treatment of COVID-19, especially in hard-hit Latin America. People with Long COVID reported remarkable recoveries after taking the medicine. But what is the evidence for Ivermectin? …

Did a strange lab leak cause the COVID-19 pandemic?

Photo by KOBU Agency on Unsplash

In November and December 2019 a novel corona virus began circulating in China. The world -and China’s citizens- first learned of this thanks to a group of Chinese whistle blowers , including Opthamologist Dr Li Wenliang, who would ultimately die of the virus. These whistle blowers were denounced by their administrators and some of them -such as Dr. Wenliang- received a police warning. After he died from COVID-19 on February 7, 2020 there was a wave of popular outrage, and sympathy for his pregnant widow, which caused authorities to censor Chinese social media platforms. So the Chinese state sought to conceal the COVID-19 outbreak in its early stages, much as it once did with SARS. But where did the virus come from? And what do we know about its origins?

Wet markets have often been associated with the start of earlier outbreaks of infectious diseases, such as avian influenza and SARS. This makes sense because these environments bring together a diversity of wild animals that may carry unknown pathogens. Packed into cages in poorly ventilated areas, viruses can passage across the species barrier in a way that would be difficult to achieve in the wild. When the outbreak first appeared in China, many people first looked at cases that appeared to be associated with a local wet market. But as earlier cases became known, the tie to the wet market lacked strong support in the data, although a recent study perhaps strengthens this case.

Attention turned to the Wuhan Institute of Virology (WIV), which reportedly had collected novel bat viruses, including some from a cave in Yunnan. Lab leaks have caused pandemics before. For example, in 1977 an influenza pandemic swept the world. Because the virus was nearly identical to historical samples from an earlier outbreak, there have been suspicions that it began as a result of a lab leak in the Soviet Union. Gain of function experiments -in which scientists deliberately increase either the transmissibility or infectiousness of an infectious agent have been controversial for many years for this reason. Accidents have happened.

Nearly a decade ago I was attending an influenza conference in Oxford, and happened to have breakfast with three well-known figures in the field of influenza virology. One of the people at the table was an outspoken advocate for gain of function research. This person’s work had attracted international controversy on this issue. He/she was an outspoken, confident person, who was more than willing to talk about the gain of function debate, and appeared to enjoy both the attention and the controversy. I thought that this person was eloquent, informed and generous in sharing their thoughts with a complete nobody like me. I was enjoying the conversation immensely. But as the discussion went on, another person at the table -a legend in influenza virology- became increasingly glum looking as he or she picked at their eggs. I felt increasingly awkward, and noticed that my charming colleague didn’t seem to be noticing their colleagues’ withdrawal from the conversation.

Finally, the gain of function researcher turned to another person -a German colleague- and said words to the effect: “You understand how these constraints are maddening.” And this German researcher said (as best as I can recall): “Yes, but I don’t do anything nearly as dangerous as you do.” One thing that I loved when I used to lecture in Germany (actually, I loved everything about Germany) was how frank my students were in giving feedback, and this response was true to form. What I took from the debate was the extent to which gain of function research worried even those people with the best practical knowledge of laboratory work with influenza viruses. As time has passed, there has been increasingly skepticism that gain of function research will produce knowledge at all worthy of the risks. But did the Wuhan Institute of Virology in fact have novel corona virus sequences, and -if so- what kind of research was being done with these strains? …

Where things went right: Bhutan and COVID-19

Photo by Kinshuk Bose on Unsplash

After so much bad news about COVID-19 globally, it helps to hear about a place that managed to vaccinate its entire population. Bhutan not only did so, but this remarkable job was done in weeks. Fortunately, this task was completed before the Delta variant of COVID-19 washed over both India and Nepal. But the story of this vaccination campaign -which was timed based on the advice of astrologers and guidance from monks- is a remarkable one, as is Bhutan’s health care system. I want to thank Paula Heimberg, a doctor who volunteered in Bhutan, for this interview in my podcast, Dispatch 7.

Shawn Smallman

The strange trip from Chronic Fatigue to long COVID

Every pandemic leaves in its wake people who survived, but were changed by their infection. The most famous example of this is likely encephalitis lethargica, which famously reduced some people to living in a near coma after they survived the 1918 influenza pandemic. For decades some people have been arguing that Chronic Fatigue Syndrome (and perhaps chronic Lyme disease) are also caused by viruses and bacteria, which cause immense but hidden damage in the body. These sequelae endure after the initial infection subsides. Over the last several months many people who were infected by COVID-19 have developed long COVID, a syndrome that remains a medical mystery. One of my favorite new podcasts is Unexplainable, which looks at scientific mysteries. Their recent episode, “The Viral Ghosts of Long COVID” paints an unsettling picture of this disorder. The podcast begins with someone describing the long term effects of their Ebola infection, which closely resemble the symptoms reported by COVID survivors. Many people now wonder whether more research on Chronic Fatigue Syndrome earlier might not have made us better prepared to face this new challenge now.

Shawn Smallman

The odd reasons for Taiwan’s COVID-19 outbreak

I am fortunate to be a Taiwan Fellow this fall. I plan to study Taiwan’s response to the COVID-19 outbreak at National Taiwan University starting this September, where I am being hosted by the global health program. I just received my visa to travel to Taiwan last week. Unfortunately, there is currently a growing outbreak in Taipei. I first heard of it last week, when I was talking with my conversational partner in Taiwan. At that time, she said that the outbreak was still relatively small, as it involved perhaps thirty individuals. But this morning I had an email and a text -the latter of which was sent to everyone who recently received a visa- to say that Taiwan is halting all travel to the island, except for residents. I am hopeful that Taiwan will soon have the situation back under control. But what happened?

Taiwan received human intelligence about the outbreak in China in December 2019. Taiwan acted quickly, in part because it’s political leaders remembered the SARS outbreak in 2003. Since that time, it has used digital apps for contact tracing, mandatory quarantine hotels for travelers, and an effective public health system to contain COVID. Then some odd things happened. Angelica Oung has written a fascinating story (How Taiwan Finally Fell) recounting how a Taiwanese hotel decided to offer a tourism package so that Taiwanese could stay in a hotel near the airport and watch the flights land and depart from their rooms. The local tourism board even advertised this. Although the people were housed on different floors from airplane crews, somehow infected pilots and crews spread the virus to the domestic tourists. After nine pilots tested positive the domestic tourists apparently found out that they had been staying at a quarantine hotel by watching the TV news. But by this point some infected people attended a Lion’s Club meeting, went to karaoke, and then attended “Grandpa shops/tea parlors” in which older women sexually catered to a senior clientele. Genomic testing revealed that everyone with COVID-19 had been infected by the same English variant. …

Singapore’s strange ad to vaccinate

Photo by Pang Yuhao on Unsplash

All around the developed world nations and local governments are trying to persuade people to go have a COVID-19 vaccination. Where I live, I am flooded with ads, which are mostly politicians and public health authorities. These ads mostly have a talking head format, so they don’t have a lot of visual interest. And no catchy songs. Then there is Singapore’s approach.

Singapore’s most recent ad highlights a comic duo, a musical number, uni-color background shots, Singlish and dance. I’m not sure where I first read about this two minute ad, but it shows another approach to public health communication. Here in the United States, I hope that we’ll see ads with football quarterbacks, basketball players, religious leaders, movie stars, musicians and others. People need to see spokespeople supporting the vaccine who aren’t epidemiologists. And maybe somebody else could do a musical about vaccinating. “Steady pom pi pi” everyone.

Shawn Smallman, 2021

Photo by Pang Yuhao on Unsplash

The most popular source for COVID-19 information?

Photo by Martin Sanchez on Unsplash

Who would have guessed that one of the most popular sources for regular COVID-19 information would be a retired nurse teacher in northern England? By this point in the pandemic, one would expect that the last thing that anyone would want to hear would be more news about COVID-19. Yet people turn in daily for Dr. John Campbell’s YouTube update, which usually feature Winston -a stuffed dog- wearing a mask in the background. One of the reasons that the show is so popular is Campbell’s English humor, his guests from different parts of the world, and his concise description of major trends in the pandemic. 

I don’t always agree with all that Dr. Campbell suggests, such as the strength of the evidence for vitamin D as a means to decrease the risk of severe COVID-19. But I enjoyed watching him debate the issue with a vitamin D skeptic, who was also a leading researcher in this field. Such reasoned and respectful academic debate is too rare now. I have similar doubts regarding ivermectin as a COVID-19 treatment, although I would also love to see data that proved me wrong. Perhaps Dr. Campbell could invite a similarly skeptical expert onto his channel for a reasoned and informed debate about the evidence for and against ivermectin? Still, his daily summaries are a wonderful tool to keep pace with global COVID-19 trends and events.

As I write these words, the situation in India is truly dire. I’ve just been texting with a friend in the country, who said that so many bodies are being burned that their city is covered in smog. The Daily, a news podcast of the Times, has a remarkable episode about what is happening in India now. As an article in Canada’s National Post suggests, India’s experience is a warning to the rest of the world about what can happen if a nation becomes overconfident that they have managed the pandemic. But India is not alone, as COVID-19 cases are also surging in Chile, despite a high level of vaccination with a Chinese vaccine. In the United States numbers are in a steady decline, despite an uptick in both Colorado and Oregon. But we still have a long way to go in this pandemic. In many parts of the world, such as Thailand and Cambodia, the situation is worsening. And Japan is still holding the Olympics, even though most of the country’s citizens do not want to host it. 

Shawn Smallman, 2021

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