“In December 2019, a series of pneumonic cases of unknown cause emerged in Wuhan, a large city of 11 million in central China, with a clinical presentation resembling viral pneumonia. The number of cases increased rapidly. The overwhelming majority of the hospitalised patients had been exposed to the Huanan seafood market; therefore, it was first believed, as on many occasions in the past, that coronavirus was spread by animal-to-human virus transmission. By 9 January 2020, the Chinese Centre for Disease Control and Prevention succeeded in identifying the virus responsible for the outbreak as a novel coronavirus named COVID-19.”
The Biology, the History, the Challenge and the Outlook
In December 2019, a series of pneumonic cases of unknown cause emerged in Wuhan, a large city of 11 million in central China, with a clinical presentation . resembling viral pneumonia. The number of cases increased rapidly. The overwhelming majority of the hospitalised patients had been exposed to the Huanan seafood market; therefore, it was first believed, as on many occasions in the past, that coronavirus was spread by animal-to-human virus transmission. By 9 January 2020, the Chinese Centre for Disease Control and Prevention succeeded in identifying the virus responsible for the outbreak as a novel coronavirus named COVID-19.1 On 29 January, medical scientists provided evidence for human-to-human transmission of this virus.2 In The Lancet,3 Chinese authors published the clinical symptoms observed in patients infected with the novel coronavirus, including fever, dry cough, sore throat, shortness of breath, muscle aches, runny nose and pneumonia. Very soon, Chinese medical doctors published a review article in the prestigious journal JAMA4 summarising their experiences with 138 hospitalised patients suffering from pneumonia caused by COVID-19. They pointed out that a characteristic of this virus is that older population over 65 are at higher risk.
These publications and several others became accessible online beginning with 29 January and became available in printed versions in March. The China CDC Weekly,5 in an issue dated 18 February, provided a calculation of the death rate due to virus infection as 2.3 per cent in mainland China, which is much higher than the 0.1 per cent rate observed for seasonal influenza viruses (which include the influenza A and B viruses). An epidemic of influenza, which is normally endemic and not a pandemic, occurred in 2009, identified as the swine flu. After more and more confirmed cases of COVID-19 had been reported in China, and the outbreak continued to spread outside the country on 30 January 2020, Tedros Adhanom Ghebreyesus, the WHO Chief, declared the situation a public health emergency of international concern. By March, the Chinese government, which had imposed very harsh measures to lock down the epicentre of coronavirus endemic, proudly proclaimed that they had succeeded in stopping the virus, as there were no new confirmed cases.
It is a duty of the European Centre for Disease Prevention and Control (ECDC) to provide assessments of public health threats for EU/EEA countries. In their Executive Summary on 13 February, when more than 60,000 cases had already been reported, they summarised the situation by stating that “the risk associated with SARS-CoV-2 infection for the EU/EEA and UK populations is currently low”. While the number of cases in countries outside of China (for example, South Korea and Japan) were increasing, the ECDC, in their Executive Summary on 23 February, stated that “the risk associated with COVID-19 infection for people from the EU/EEA and the United Kingdom (UK) is currently considered to be low to moderate”. In fact, by mid-March, most member states of the EU were forced to bring strict measures of varying degree to cope with a severe pandemic.
HOW IS THE WORLD RESPONDING?
As we have seen, in January and February, opinions varied worldwide; it was stated that “the coronavirus was not a big deal”, and someone even called the pandemic “a bloated psychological situation”, whereas other regions began declaring a “state of emergency”. Some governments even adopted wartime measures — closing borders and schools, enlisting industry to produce medical equipment and devices, advising and even ordering people to stay at home, closing airports, sending military to help police and local administrations to keep order, seizing medical devices and drugs destined for export, and locking down their cities. So — what had really happened?
The official agencies (WHO, EDCD) have failed to meet people’s expectation that they would forecast the danger in good time. It became a general feature of coronavirus management in Europe that national governments started to handle the pandemic independently from one another and the EU administration. The European Union has failed to help worst-hit countries promptly (e.g. Italy) and to organise a joint effort to this day. It has failed to show effective solidarity. In a few countries, governments did not introduce measures promptly because they were advised to allow the virus to spread — in other words young people, in principle not threatened by severe consequences of the virus, were allowed to move around and mix as usual. In other cases, like Sweden, their confidence in their health care systems had been rather high.
By contrast, other governments, for example those of Hungary and Austria, declared a “state of emergency” on all fronts soon, and decided to fight hard against the virus from the very beginning by using legal measures (imposing stay-at-home orders), establishing task forces, closing schools and trying to isolate people who had contact with coronavirus-infected patients; in order to reduce the infection rate, these people were placed in quarantine for 14 days. Special care has been taken of people (health care workers, ageing people etc.) who are at higher risk.
Both countries brought in these strict measures, enforced if necessary with the help of police and military, and thereby they succeeded in delaying sporadic first cases becoming clusters and in preventing those clusters becoming community transmission. The situation needs permanent alertness from these governments: walking the line between concerns about public health, the citizens’ comfort and the running of the economy.
In Hungary, a special measure was taken to protect medical doctors and nurses who worked and have been working in a traditionally well-organised family-doctor network, from being infected by people with Covid-19 symptoms. New cases are asked not to go to the doctor’s office but first to call their doctor and speak to them, and the doctor would arrange an ambulance to bring tests to their homes, and transport them immediately to the hospital for treatment if necessary.
In these countries with populations that complied with regulations fairly well and followed the measures declared by the government by staying home, the number of infected people and the spread of the disease have been dramatically reduced and resulted in reduced death. They significantly flattened the curve that reflects the number of people needing hospital care at the same time. These governments have also prepared a wide range of economic rescue operations including tax relief and financial support to help families by maintaining employment and the pace of activity in commerce and industry.
There has also been a third type of response from national governments, in cases where the government initially did not take the virus threat seriously, but then suddenly took the helm firmly in handling the crisis (e.g. Italy, Great Britain and the USA). For example, in England, researchers at Imperial College, London alerted the British Government to change their response strategy as late as 16 March. By 23 March they convinced the government to treat the situation very seriously and advise people to avoid social contact. After a rather long delay in taking such measures, together with mixed messages coming from the Trump administration about the real threat of Covid-19, America ranks number one in terms of the number of documented infections and death rate.
These are the various ways in which the world has responded to the initial phase of COVID-19 pandemic. Yet we are far from the time when conclusions can be drawn. The virus is currently raging all over the world, and though the peak of the first wave may have been reached in some countries, new developments may yet be in store.
THE GREAT PANDEMICS OF THE PAST
In the 14th and 15th centuries, plague, also called the Black Death (once called pestis and produced by a bacillus) killed approximately 20 million people all around the world. The bacillus, which enters the lymphatic system, produces characteristic swelling (“buboes”) in the armpit, groin and neck. Therefore, the disease was also called the bubonic plague. The great storyteller Boccaccio,6 in the introduction of his classic Decameron, gives an authentic description of people suffering from pestis who were ultimately expelled from Florence. Throughout the 18th century, plague still remained a threat in Europe. However, the historical discovery of sulphonamides by Domack7 in 1935 fully eradicated pestis epidemics.
New World people, named “Indians”, were massively infected by the whole array of European contagious diseases (smallpox, measles, diphtheria, plague, malaria and cholera) imported by sailors and conquerors. These diseases swept over both Americas, resulting in a 40–90 per cent loss of their 16th century population.8 While the toll these pandemics took also enabled European colonisers to first invade Mexico and then South America easily, at the same time, the rapid decline in the native population resulted in a deficit in the labour force. To replace the native population, the colonisers initiated the transatlantic slave trade from Africa. Due to the colonisers, in particular to the Spanish conquest of America which introduced a new culture (European civilisation), the native populations of the Americas soon became minorities in their own territories.
Malaria, which is believed to have originated from Africa, affects more than 300 million people annually worldwide and kills about two million people each year. The protozoan parasites (Plasmodium falciparum) are transmitted from one human host to another by the bites of female Anopheles mosquitoes.9 Already during the Second World War, in both the German and American militaries, enormous efforts were made to find drugs to fight malaria. Due to further research, drug treatment with chloroquine10 and finally a vaccine have been developed, and the death toll has been significantly reduced. In 2018, there were 228 million cases worldwide resulting in an estimated 400,000 deaths. This figure is still very high, mainly due to a lack of money in poor, mainly African countries and lack of available drug treatments. Therefore, it is still considered as one of the most serious endemic diseases in the world.
The 1918 influenza,11 also called the “Spanish Flu”, was the most severe pandemic in recent history. After the Great War, the flu killed more people than were killed in the War itself. About one third (500 million) of the world population became infected, and nearly 50 million died,12 equivalent in proportion to 200 million in today’s global population. The characteristics of this flu were such that it was young people and healthy children who were mainly affected by it. The high mortality was due to the weak health care systems of the time, a lack of vaccines to prevent virus infections, and a lack of antibiotics to treat secondary bacterial infections. Subsequent influenza pandemics in 1957, 1968, and 2009 failed to be as severe, and the levels of morbidity and mortality were much lower than that of the 1918 influenza.
There are several good examples of how science has helped humankind to overcome difficulties. Due to WHO activity, the worldwide eradication of smallpox was in fact the first case in history when a disease has been entirely eliminated through the achievements of medicine. In 1966, 10–15 million people still caught smallpox yearly, and 2 million died. However, another disease, TBC, though believed to have been eliminated, has returned. Before antibiotics were introduced, the pneumonia fatality rate was approximately 30 per cent, but today, it is less than 0.1 per cent.
Furthermore, the discovery of antibiotics, heart transplantation, in vitro fertilisation, genetic engineering, and treatments with biotechnology and tailor-made medicines have changed the world. While vaccines have had success in preventing viral (e.g. smallpox, measles, mumps, rubella and poliomyelitis) and bacterial (diphtheria, tetanus, and pertussis) infections, no drug is available for acute and prompt efficient treatment of virus induced diseases. Viruses are intracellular parasites, and therefore drug treatments against viruses have until now proved to be unsuccessful.
In addition to the developments seen in medicine, improvements in social conditions have reduced infant mortality and increased life expectancy, resulting in a steady rise of the world population, which has reached 7.8 billion. However, it must be pointed out that the enormous developments in medical science, biotechnology, chemistry, physics, drug treatments and the diagnostic technologies used in everyday medical practice entail costs that have made health care unaffordable to many people, and this may have dire consequences in crisis situations.
HOW TO SURVIVE THIS CRISIS?
Two years ago, Science, one of the most prestigious scientific journals, published an editorial “The 1918 Flu, 100 Years Later” that discussed the experiences of the past and concluded that “we are no doubt more prepared in 2018 for an infectious disease than in 1918”.
Yet the fact is that even very active reporting in the last decade about epidemics caused by the Ebola13 virus infection failed to be successful in teaching governments how to deal with such epidemics. The most important lesson for the governments and the public — lessons that should have been learned from previous pandemics — is that virus infections should be taken seriously from the beginning. In addition, public vaccination programmes seem to be very important. In Hungary the immunisation is mandatory against 11 diseases, parents who fail to have their children vaccinated can be fined. According to the Hungarian Health Authority 98 per cent of the population has been vaccinated. But this, as we know, is not characteristic or many countries in the world. Just an example: the United Kingdom (UK) recently lost it measles-free status, because of the fall in rates of immunisations.14 According to The Guardian15 the fact that the childhood vaccinations have been falling year on year had prompted health care experts to warn of a potentially devastating impact in UK.
HOW SHOULD POLITICS BEHAVE DURING A PANDEMIC?
A pandemic should certainly not be the time for politicians to fight one another in parliaments and the press. On the contrary, it should be the time for joint efforts. Any political attack thwarting well-planned government action may divert attention from the Covid-19 crisis, with fatal results. As opposed to trumped-up internal and international charges of authoritarianism against Hungarian Prime Minister Viktor Orban, who has merely concentrated government mandates for handling the pandemics — and has been doing it fairly well so far —, there are several good examples of international cooperation among countries of Central Europe. Or there is the case of General Benny Gantz, who had nearly defeated Benjamin Netanyahu, Israel’s Prime Minister in the recent elections, and who declared his intention to be ready for joint efforts in a coalition to combat the Covid-19 pandemic. Another good example is North Rhine-Westphalia, Germany, with a population of 18 million, where the members of its Parliament (Landestag), independently of their political background, decided to make a joint administrative effort against virus pandemic. This part of Germany is the most affected state, the hotbed of the Covid-19 virus outbreak, where more than 1,000 Chinese businesses operate in the region. As far as Angela Merkel is concerned, she said: “Taking it seriously. Not since German reunification, no, not since the Second World War has our country faced a challenge that depends so much on our collective solidarity… I truly believe we can succeed in this task.” Indeed the German government has decided to provide significant financial and psychological support for the German states in trouble.
CAN WE BEAT THE CORONAVIRUS?
As has happened in the past, an epidemic of a killer disease with its origin out there somewhere in the world again makes its appearance when least expected, with enormous consequences for healthcare systems and economies — and possibly, mankind’s future history. The immediate result is soaring death rates and emergency government measures.
The new virus, Covid-19 has spread to more than 300 countries, and by now the total number of people infected and dead worldwide has passed 2 million and 100,000–200,000, respectively.
Within one or two years, the number of infected people is expected to reach 60 to 70 per cent of the population and our lives are expected to return to normal.
According to such calculations, by then the overwhelming majority of citizens will become immune and safe from Covid-19, either through vaccination, or developing immunity through infection. This virus is a strain to which the human being is immunologically nai’ve; our immune cells are not prepared to combat this novel virus, which is an intruder. Our immune cells are not yet ready to fight it because they were not taught to do so and are therefore unable to remember how to do it. There are many laboratories around the world working to develop a vaccine16 against the COVID-19 virus.
A final outcome also depends on the adequacy of governments’ scenarios based on projections of the future, and their actions in the present. Whether they succeed in providing for the common good, in the interests of citizens, and in keeping the economy running. The final numbers of people needing treatment, the number of deaths, and the economic loss depend on the efficiency of governments and whether citizens are in compliance with orders. Nearly a third of the world population are living under coronavirus-related restrictions, resulting in unforeseeable problems in the economy.
The present-day data lags one or two weeks behind in terms of how the virus is spreading and how it will influence the economy, small and medium-size companies, cultural life, human privacy and family life. The theatres, concert halls, and stadiums will remain closed until the end of the crisis, and surely some of them will not be able to open again. Culture, including science and sports, will suffer. According to an estimate published by economists, the jobless rate in the EU could reach a high level as millions of workers are laid off due to the Covid-19 outbreak.
People who see recession instead of development and restrictions instead of freedom, who are finding their enforced isolation difficult, have and had enough time to think about the years to come. People feel anxious because they are fearful of what is to come and what has to come, and we are certain that it will come. The enemy is invisible, an 80 nm17 living organism. When our immune system has learned to overcome the virus and how to combat the disease, the virus may still be able to mutate, and a change in the biological sequence is enough to trigger another epidemic or even a future pandemic. One philosophical reading of the events is that endemic and pandemic either produced by a virus or bacteria result in an ever-lasting fight between humankind and nature.
The question arises: will China be the winner of this human catastrophe? Shall we have an economic and political turning point, the centres of power sliding from the hands of the Western world including America and the EU18? It is very difficult to predict anything. After the Shoah, after the Second World War, a “European Union” was the hope of many politicians involved in the rebuilding of the historical continent whose function was based on Jewish-Christian inheritance, Roman law and the modern European intellectual movement of the Enlightenment. At the University of Zurich on 19 September 1946, Winston Churchill talked about a joint effort of European nations as the only way to establish a conflict-free new Europe. He said the following to the students: “This noble continent, comprising on the whole the fairest and the most cultivated regions of the earth, is the home of all the great parent races of the western world. It is the fountain of Christian faith and Christian ethics. It is the origin of most of the culture, the arts, philosophy and science both of ancient and modern time. If Europe were once united in the sharing of its common inheritance, there would be no limit to the happiness, to the prosperity and the glory which its three or four hundred million people would enjoy.”
One thing is certain, that the current world population represents the best-informed society in history due to the information revolution and globalization. People who see recession instead of development and restrictions instead of freedom, who are finding their enforced isolation difficult, have had enough time to think about the years to come, about their representatives in legislative assemblies and in international agencies. They will think about the fact that since 1980 income inequality has increased in nearly all countries and the incomes of the global middle class have been squeezed.19 It is high time to think about our common future: the future of humankind and the future of Europe and the globe where we have been living for a few hundred thousand years.
Notes:
1 According to the World Health Organisation severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the official name of the virus that causes coronavirus disease 2119 (COVID-19). The Covid-19 genome was rapidly sequenced by Chinese scientists and comprises an RNA molecule of approximately 30,000 bases containing 15 genes. For comparison, the genome of a human being, which is in the form of a double helix of DNA, contains approximately 30,000 genes. The coronavirus could be a “chimera” of two different viruses according to genome analysis.
2 New England J. of Med, doi:10.1056/NEJMc2001272.
3 Huang et al., The Lancet, 395:497–506, 2020.
4 JAMA, The Journal of the American Medical Association, 323:1061–1069, 20 February 2020.
5 Chinese Centre for Disease Control and Prevention.
6 Giovanni Boccaccio (1313–1375): Italian writer, poet.
7 Gerhard Johannes Paul Domack (1895-1964): Nobel Prize winner for the discovery of the first drug effective against bacterial infections.
8 Cambridge Illustrated History of Medicine, ed. Roy Porter, Cambridge University Press, 1996.
9 A Scottish physician, Sir Ronald Ross, revealed the complete life-cycle of the malaria parasite in mosquitoes, and received the Nobel Prize in Physiology and Medicine in 1902.
10 Despite lack of evidence the US Food and Drug Administration has authorised clinicians to prescribe chloroquine and hydroxychloroquine for patients admitted to hospital with COVID-19 (28 March 2020, https.fda.gov/media/136534).
11 The N1N1 virus was responsible for the pandemic.
12 Centres for Disease Control and Prevention.
13 Ebola disease (virus) is a rare but severe, often fatal illness in humans.
14 National Health Service Digital for England.
15 26 September 2019.
16 A vaccine is a preparation made from weakened or killed forms of the microbe (virus) that are able to stimulate the body’s immune response to make antibodies that recognise the virus and kill it.
17 Billionths of a metre.