global health

How quickly can you catch COVID-19?

Throughout the last several months, the US Center for Disease Control has messaged that in order to catch COVID-19 you had to be within six feet of an infected person for fifteen minutes. This was reassuring information. But sadly the US was also perhaps in a difficult place to answer detailed questions about COVID cases, because the contact tracing system has been overwhelmed. The US has also lacked a national COVID tracking app, as many other nations (Australia) have had. Realistically, this would have been a political impossibility to implement in the US, given that even masks have been highly politicized here. So, how realistic was the CDC’s guidance?

The CDC itself pointed to a case in Vermont in which a masked corrections officer was infected with COVID even though he never spent more than a single minute with infected prisoners. Instead, he spent perhaps a total of 17 minutes in a day with them over the course of multiple brief visits, all of which were captured on video. He also wore a mask, gown, and goggles. The prisoners sometimes wore their masks, and sometimes not. After this case, the CDC changed its rules to reflect cumulative exposure. Still, the fifteen minute rule still held. But would new information change these guidelines?

In Korea, contact tracing has been highly effective. It turns out that the combination of a digital tracking app with highly skilled contact tracers has been more successful than either purely digital or human tracing would be. And what Korea has learned -in a remarkable piece of scientific work- is that in one case a high school senior was infected after five minutes of exposure and from twenty feet away. The infection took place in a restaurant (which had video recording) and it turns out that an air conditioning unit was wafting air from an infected person towards the student. The quality of the data that the contact tracers obtained -and the history of how they learned it- is remarkable, and well worth reading.

There is nothing magic that happens at the six feet mark from another person. And being exposed to an infected person indoors can be risky even when the CDC’s old guidelines might make us feel safe. In this case, Korea has given us not only important information, but also let us see the quality of information contact tracing can provide. The key message is that neither six feet of distance, or avoiding more than fifteen minutes of exposure to another person, may be enough to keep you safe from infection, particularly indoors. So indoor dining is probably always unsafe.

Shawn Smallman

Do we already have a vaccine to prevent COVID-19?

Bust and Plaque at the Fighting SARS memorial, Hong Kong

A recent study published in the American Journal of Microbiology journal, MBIO, suggests that MMR 2 vaccine helps to prevent COVID-19 symptoms. It’s a study based on a small population (80), but the MMR blood titers show a very strong association with the severity of COVID-19 illness. People with high titers were all asymptomatic. Everyone who became severely ill had titers under 32. This wasn’t the first article exploring this idea of an association between MMR vaccination and COVID-19 resistance. But it’s an intriguing one that deserves more attention and research.

As a press release from the American Journal of Microbiology states, this could also explain why children don’t seem to get seriously ill. The MMR blood titers fall as you age. And the elderly may never have had this vaccine, in part because they’ve had measles or mumps. One significant point to the study was that having had the mumps doesn’t protect you. People need to have the vaccine itself. This contradicts the argument of vaccine critics who say that it’s better to have natural immunity. But in this case, the vaccine seems to give better immunity. As someone who had mumps as a child (and then gave it to my sister) I’m in favor of a vaccine-based approach to public health, rather than natural or herd-immunity.

I want to emphasize again that this study was based on the MMR blood titer results of only eighty people who had COVID-19. So this is a preliminary study. But the risks of the MMR are very low; at least hundreds of millions of people have had it since it was first introduced in 1971. Please note that this study only examined the MMR 2, not the quad vax, which also includes varicella.

Even though new COVID vaccines are coming soon, it will take months to roll the out at scale. It would be wonderful if we could use an existing vaccine with a long track record for safety to help us to buy time.

Shawn Smallman

Laura Spinney’s Pale Rider: A book review

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

After the wonderful histories of Alfred Crosby and John Barry, readers might wonder if there is truly anything new left to write about the 1918 influenza pandemic, which killed between 50 and 100 million people world-wide, at a time when the world’s population was much smaller. Laura Spinney’s detailed, beautifully written and insightful work shows how much study can yet be done on this topic.

As Spinney describes in the opening to her book, in the 1990s much of the writing on this pandemic had been done on Europe and the United States. Of course there were exceptions. In Canada Eileen Pettigrew created a rich narrative of people’s experiences from survivors accounts, while Betty O’Keefe and Ian MacDonald told the story of how medical officer Fred Underhill fought the disease in Vancouver, Canada. There were similar accounts of popular experiences with the pandemic in other countries, such as Australia and New Zealand. But voices in Asia, Latin America and Africa were often not included. Since the 1990s there has been a plethora of work in many different nations, at the same that scientific advances have made it possible to have a much better understanding of the pandemic.

Spinney’s history takes full advantage of this study. She also has a gift for seizing upon the lives of individuals to tell a broader story, whether it was a young man in Rio de Janeiro, Brazil or a scientist in Republican China. She weaves together these narratives to create an overarching view that is truly global. After reading the work I find myself curious to learn more details on individuals, such as a woman affected by the pandemic in South Africa, who then created a religious (and perhaps millenarian) movement.

While such individual accounts are powerful, I particularly like chapter fifteen, in which she described how the same virus had dramatically distinct impacts in different places. Why would the same disease cause mortality rates in excess of 80 percent in some remote Alaskan and Labradoran villages, and far lower rates elsewhere? Of course, the flu was not unique in this respect. I wrote an entire book trying to understand the diversity of HIV epidemics in Latin America. What is perhaps most striking to me is that after a century of earnest study, many of these questions remain unanswered.

What is clear was that the pandemic utterly devastated some locations. In Western Samoa, twenty-two percent of the population died. In the Pacific, on the island of Vanuatu perhaps 20 languages died because of the heavy mortality that the virus brought. Given Brazil’s catastrophic response to the COVID-19 pandemic, and the disproportionate impact that the virus is having on Brazil’s Indigenous peoples, might something similar happen in the Amazon rain forest now? As Spinney states, there was a strange paradox to the virus. Cities often saw high mortality rates, but isolation caused terrible vulnerabilities in remote communities.

What was also striking to me was her discussion of the influenza’s aftermath. In part, this was reflected in such societal trends as a loss of faith in science. Will we be struck by a similar trend with COVID-19? But there was also a physical legacy of the virus, as many people suffered either psychological trauma over the loss of loved ones, or debilitating physical effects that lingered long after the virus was gone. Of these, perhaps the most famous was encephalitis lethargica. While it cannot be proven that the 1918 influenza pandemic caused this disorder -again so much remains unknown about this tragedy- the onset of the one was accompanied by the emergence of the other, as some people remained paralyzed -but apparently aware- for decades. Will COVID-19 have similar health effects that linger for more than a generation? The thought is chilling, given that one recent pre-publication from Korea just reported that up to 90 percent of COVID-19 survivors still report symptoms months later.

Still, what most struck me is that we are now having the same debates now that we had over a century ago: “One 2007 study showed that public health measures such as banning mass gatherings and imposing the wearing of masks collectively cut the death toll in some American cities by up to 50 percent (the US was much better at imposing such measures than Europe).” While now it is the US struggling to persuade its citizenry to wear masks, there is a haunting quality to the debates from this time. Some challenges that faced public health authorities then echo during the COVID-19 pandemic now, although (as far as I know) the death threats and public vilification of public health leaders was uncommon in America a century ago. So perhaps things have gotten worse. Spinney’s last two chapters are remarkably prescient for a book that was published in 2018.

I’ve spend much of the last twenty years working on public policy and infectious disease, first with my book on HIV/AIDS, and more recently with Zika and avian influenza. Some factors are constant, such as the fact that conspiracy theories emerge with every pandemic. One of the most common human urges when faced with an outbreak is to find someone to blame. But what depresses me is that I don’t think the historical studies or public policy achievements make much difference in the long run. In 2018 I published an article on wet markets in Hong Kong, which recommended that the special administrative region consider closing them. Of course, COVID-19 did not emerge in Hong Kong, but likely from a wet market in eastern China. One of the reasons that I hate conspiracy theories is that the distract from the real actions that could make people safer. They also make pandemics and outbreaks seem mysterious and unpredictable.

In fact, people have been studying coronaviruses in China since SARS emerged in 2003 precisely because such an event might take place. This was entirely predictable. As I said in an earlier blog post, how much human suffering might have been avoided if China’s wild game markets -which particularly cater to an older and wealthier clientele- had been closed. Yet even the Chinese government -with all its power and influence- either would not or could not do this. And now social media accounts spread tales that this outbreak is caused by 5G, and people in Britain burn cell towers. Two million people have died globally and winter is drawing closer in the northern hemisphere. We all know what happened in November 1918. Now we must now hope that a different virus will have a dissimilar impact.

Yet behind the scenes scientists have laid the groundwork that will allow for vaccines to be more quickly developed, because much basic science work has been completed. For all the frustration with sciences’ failures and limitations, the hope that we have now doesn’t come from conspiracy narratives -which don’t lead to any constructive steps- but from the often ignored work by nearly anonymous scientists in global laboratories. This work lacks the drama of the conspiracy theories, but the time-consuming and methodical study has laid the groundwork for the greatest vaccine push in human history. Conspiracy theories are easy to create. Real public policy or scientific advances are far more difficult, time-consuming and (often) difficult to understand. Spinney’s work is built upon a detailed examination of both the historical and scientific literature that has been built up over the last century, particularly the last twenty years.

It has long gone out of fashion in academia to look for lessons or a moral in history. But if this line of thinking is taken too far, it might lead people to question the value of history entirely. If historical study cannot give us lessons for the present period, isn’t it little more than a hobby for the affluent few? Laura Spinney’s brilliant book shows how a careful understanding of history can provide us the context to better understand current challenges. Sadly, in this current moment, it’s probably difficult to interest people in reading a work about a past outbreak. Spinney’s magisterial, carefully researched and beautifully written book deserves a broad audience. Highly recommended.

References

Spinney, Laura. Pale Rider : The Spanish Flu of 1918 and How It Changed the World. First US Trade Paperback ed. New York: PublicAffairs, 2018.

See also the following works for more reading on this topic.

Barry, John M. The Great Influenza : The Epic Story of the Deadliest Plague in History. New York: Viking, 2004.

Crosby, Alfred W. America’s Forgotten Pandemic. West Nyack: Cambridge University Press, 2003.

Canadian popular histories:

O’Keefe, Betty, and Ian Macdonald. Dr. Fred and the Spanish lady: Fighting the killer flu. Heritage House Publishing Co, 2004. (Full disclosure: this press also published my history of an evil spirit in Algonquian belief. Please note that I have no control over the price of physical copies of this book on Amazon, which sometimes surges to hundreds of dollars for mysterious reasons. So if you click on this link for my book, please don’t send me unhappy emails to complain about the book’s price).

Pettigrew, Eileen The silent enemy: Canada and the deadly flu of 1918. Saskatoon: Western Producer Prairie Books, 1983.

Shawn Smallman

HIV/AIDS, an “Introduction to International Studies” class lecture

Mercator Map of the Congo, 1595, from the Northwestern University Library Maps of Africa collection, accessed through Wikipedia.

I wrote a book, the AIDS Pandemic in Latin America, and have studied public policy and infectious disease for nearly twenty years. Here is a lecture that I wrote (around 2010?) for an “Introduction to International Studies” class. It would need to be updated now; it may also some references to my own experiences, which would need to be removed. But my hope is that it might prove a useful starting place for someone who wants to do a lecture on this topic in a similar class.

Shawn Smallman

HIV/AIDS

Terms:

clades

HIV 1-B

HIV 2

Retrovirus

Cameroon

 

Character of the Virus:

  • HIV is not one virus but many
  • The result of more than one introduction into humanity
  • Two main forms: HIV-1; HIV-2
  • Great diversity
  • Difficult to create vaccine
  • 10 year latency
  • initial infection- blood/sex/mother daughter
  • flu-like symptoms
  • body holds the virus in check
  • over time, the virus gradually erodes the immune system’s ability to defend the body
  • the person dies of opportunistic infections
  • there are different latency periods for different people: my Cuban experience
  • medicines don’t work with everyone: my experience in the support group in Sao Paulo
  • most people, the medications are effective
  • recently realized: in a discordant couple medications prevent transmission in 98% of cases
  • means that treatment is prevention
  • heart-breaking: long argued that treatment was too expensive
  • the only economical way to treat the virus was prevention
  • proves to have been a flawed paradigm

Ethiopia, Innovation and COVID-19

In Taiwan, before entering museums (and many other public institutions, offices, etc.), one needs to enter the Real-Name System (with one’s cellphone, by scanning the QR Code), on top of getting one’s temperature taken / sanitize hands with alcohol. By leaving one’s name and contact information, if a person got infected by COVID-19 and have been to the museum, the government will know who he / she have been in contact with. Photo by Isabella Mori.

One of the realizations that has come with COVID-19 is that the old binary between developed and developing countries is deeply flawed. Some nations that are less wealthy (Vietnam, Thailand) have succeeded very well in limiting the virus’s spread (at least in June 2020), while some wealthier countries (the United States and Great Britain saw their governments fail to control the outbreak, despite not only their relative wealth, but also sophisticated health care systems.

In the United States the CDC and FDA decided not to adopt a test for COVID-19 that was recommended by the World Health Organization (WHO). But their effort to create their own test was badly flawed. When that test proved not to work, it set the US testing back perhaps a month or more behind other nations at the most critical moment in the virus’s spread within the United States. In contrast, countries that adopted the WHO’s recommended test were able to test their populations at scale.

In Boston, there was a testing debacle after a number of people were infected at a Biogen conference. Even after people reported symptoms and repeatedly sought testing they were unable to be tested, because they did not meet the overly strict criteria that included travel to China, or contact with someone from China. The result was a disaster, which saw the outbreak flare so that Boston had one of the worst outbreaks in the world. Meanwhile, Vietnam carried out a very thorough testing program that has allowed to control the outbreak to this date.

One of the most interesting points for me has been the relative difference in innovation between some developing countries and the United States, which is the home of Silicon Valley. In the U.S. there is still no national contact tracing app. Instead individual states (such as North and South Dakota) have had develop their own. But at a national level, the rate of innovation has been painfully slow. In contrast, some developing countries have moved with amazing speed. One of the success stories has been Ethiopia. As Simon Marks described in an article on the Voice of America website, Ethiopian developers quickly created seven different apps to help with everything from contact tracing to supporting health care workers. What is clear is that the size of nation’s economy does not necessarily correspond to its ability to innovate and adapt. American exceptionalism aside, wealthy nations must overcome the hubris and sense of exceptionalism, which have hampered their response to the pandemic. When developed nations take an interest in the the innovations in places from Ethiopia to Thailand, their own response will improve.

A few years ago, I was in Hong Kong, Macau and Shenzhen. When I asked at a coffee shop in Hong Kong if I could pay with a credit card, the clerk said that they could do that. Would I mind waiting while they took the machine out from the cupboard? It would take just a minute to find the keys to the cupboard. At this point, I was embarrassed and ask them not to. But they wanted to help me, and insisted on hooking up the credit card machine for the foreigner. But credit cards felt antiquated in a world in people used WeChat to pay for their subway cards, get their groceries, and order deliveries. People never had touch a device to put in a PIN. When I came back, I realized how antiquated our entire payment architecture is. I think about this during the pandemic every time I go to a gas station or department store and have to first swipe a card, and then put in my PIN on a grungy pad. Of course this is the tip of the iceberg. Why do I still need to pay bills with a check in an age of Venmo and Paypal? In Australia checks have nearly disappeared as a payment form, and it has been more than a decade since most people used one. Five years ago I was talking with an Australian. She said that she was stunned when she moved to the U.S. and people still wanted checks. And why do forms in the US still ask for my department’s fax number?

In Shenzhen I saw the sophisticated drones, electronic devices, and pristine infrastructure. Afterwards when I traveled to New York and saw the state of the airport, it felt like traveling twenty years back in time. In the United States, there is a sense of exceptionalism, which equates modernity and power with being American. But from Asia to Africa there are innovations, technologies and approaches that Western nations -particularly the United States and Britain- would benefit from adopting, particularly during this pandemic. It’s not that the developed/developing binary doesn’t isn’t useful in some circumstances. But in some respects it can conceal more than it reveals.

Shawn Smallman

Dispatch 7, Anemia in Peru

Image of globe on light, McGill University. Photo by Smallman

In episode three of my podcast, “Dispatch 7: Global Trends on all seven continents” I interviewed my honors thesis student Samantha G.  Alarcon Basurto about anemia in Peru. You can find the podcast on different platforms (including Apple podcasts), as well as on Anchor here:

Shawn Smallman

Quarantined across borders, a blog

Before entering restaurants in Taiwan people sanitize their hands and have their temperature taken. Image courtesy of Isabella Mori.

Recently my colleague, Dr. Priya Kapoor, shared a blog with me “Media Rise: Quarantined across borders.” Every day, two or three new blog posts are added. What I like about this site is that it focused on the personal experiences of people who have impacted by COVID-19, from a Pakistani study-abroad student in China, to an American facing anti-Asian discrimination. Each piece is quite brief, perhaps just a couple of pages, but they still provide an interesting point of view on our diverse experiences during the pandemic. I particularly recommend Dr. Kapoor’s piece, which speaks to how adults connect with distant parents during a pandemic, and the ties that bind a family.

Shawn Smallman

The 1918 pandemic and COVID-19

Food market in Taiwan. Note the plastic partitions separating customers. Photo taken by Isabella Mori in May 2020.

Like many people, I’ve been struck by the parallels between the current COVID-19 pandemic and the 1918 pandemic.  In 1918 many media outlets in Europe and the United States did not initially give the outbreak adequate coverage, because they were censored during the war, or did not want to reveal their nation’s weaknesses. In the United States and Brazil now, populist leaders are dismissive of the news and data on COVID-19, because it reveals their failures. For this reason, their followers tend to view all COVID-19 information through the lens of partisan politics. Indeed, President Bolsonaro of Brazil has called his followers to storm hospitals to take photos and videos to show whether COVID-19 patients are truly filling hospital beds, as the hospitals and state leaders claim. Such denial has caused painful climbs in COVID-19 deaths in both Brazil and the United States. …

COVID-19 in Latin America

Flyer for our upcoming presentation

Next Tuesday my department will be having a presentation on Zoom  about COVID-19  in Latin America. During this discussion I’ll be talking about Bolsonaro’s leadership in Brazil, and the current pandemic trends in that country. Dr. Rodriguez will be talking about Argentina’s response, while Dr. Young will be discussing the experience of both Cuba and Mexico. Since I know little about the COVID-19 situation outside of Brazil in Latin America, I am particularly interested to hear what my co-presenters will say. The talk will be 2pm West Coast (US) time. Please RSVP if you are interested in participating.

Shawn Smallman

Fear, Fact and Fiction: COVID-19’s Origins and Spread

 

Photo by Isabella Mori, who provides this context: In traditional Taiwanese night markets, since people / food stands are in close contacts, most people / vendors wear masks now, in order to protect themselves and others.

I gave a talk yesterday for WorldOregon on COVID-19, and what we know about it’s origins and spread, as compared to conspiracy theories. What you might not know when you watch this is that I wrote a talk before asking how long it should be. So I wound up having a fifty minute talk for a twenty minute delivery. Throughout the whole talk I was trying to summarize. My bad. But I had a good time and enjoyed hearing the questions. Thanks WorldOregon! …

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