A long time ago I was at a conference on Hepatitis C Virus (HCV, which is now curable, BTW) and was literally accosted by members of Fauci’s team from the Division of Microbiology and Infectious Disease. I had just given a plenary lecture on new ways to manipulate the immune system for therapy and prevention. This was right after the 911 attacks which were followed by the Anthrax mail attacks. The NIAID was given full control of the U.S. Biodefense effort right away (Bush said to Fauci — Fix it!). They recruited me into the effort that day and I was in DC presenting the slide in the title image… along with 40 or so others…. about a month later to the NIAID leadership. That was January 2002.
At that time things were really bad in the world and I, like so many others, was scared and felt helpless. This opportunity really allowed me to change the feelings of helplessness right way and even the fear subsided dramatically. This is my first piece of expert advice — Do something productive. Do something to help. You’ll feel better.
Until 2018, I was on the front lines of pandemic preparedness, emerging infections and biodefense and would be today if I hadn’t just started a new biotech focused on cancer immunotherapy, We’re not big enough yet to pivot to COVID19. Anyway, I have been consulting, watching the numbers carefully and I have been in touch with a network of former colleagues who are experts in different aspects of pandemic preparedness and are still on the front lines. Take home messages — Italy is the canary in the coal mine. Don’t count cases (testing rate is still too low/spotty). Count deaths per day. It is a lagging indicator, but the most solid trend for decision making.
If you want a worst-case for nearly everybody in the world just follow the Italian trend in daily COVID19 deaths and push things out by a few weeks (Spain has a very similar trend just delayed). It is anticipated that Italy will hit peak deaths per day in 2-3 weeks. I am not going to guess here what that peak number will be or total deaths, although I and others have some ranges. Italy is not as unique as we might want to believe, they are just showing all of us the trajectory of the virus if unchecked. They were late to social distancing/quarantine testing and they got hit hard and early. Bergamo and the Lombardia region are being decimated and it’s not just because there are lots of old people, or culture, or hospital beds per 1000 citizens etc. etc. It’s also because they likely had a huge number of infected people get together with uninfected people (perhaps some super spreaders) and the initial outbreak got ahead of any countermeasures that could be implemented. Was Italy Late in Social Distancing and locking things down? — We all were, but not by much. There are stages of alert from WHO, CDC, and Italian Health Ministries. Each is based on following data like the graph above. By the time they were mobilized for flashing red, Bergamo was already lost.
This is how it happens. This is what pandemic preparedness was/is all about. When they hit, they can go very fast, especially locally. So how did China and S. Korea get their outbreaks under control? (NB I don’t trust China’s numbers during the Wuhan outbreak in terms of death toll. They did lie about the outbreak for a long time. Not hard to imagine them teasing those numbers down 5-10X for the official count after they got everything under control — more on that later).
About two-three weeks ago, there was increased interest from experts in the tales of 3 countries — China, S. Korea and Italy. That was well before Italy surpassed China in total deaths and deaths per day (Italy is currently around 600-800 deaths per day, with ~70% still focused in Lombardia). What could explain these dramatic differences? Genetic susceptibility or resistance is impossible to rule out and is always a competing hypothesis. However, it is unlikely to explain.differences this extreme. The working model is S. Korea definitely got a big head start on testing and this allowed them to do smart quarantining and smart social distancing — Like my slide from 2001 Diagnostics and Detection are the Foundation of everything. Also, S. Korea’s outbreak seems to have started in young women, a group in Italy that is also less susceptible to serious COVID19 infections and perhaps even being less highly contagious than extremely sick elderly men. Take home message — It is possible to snuff out this pernicious little bug, but you need to act quickly and be lucky enough not to get caught in the potential black swan event(s) of Bergamo and Lombardia. There was a UEFA Cup soccer match between Atalanta (Bergamo’s Team) and Valencia from Spain in Bergamo in February. It is believed that around 1/3rd of the 120,000 citizens attended the game, while many more watched with large groups in bars etc. Atalanta won 4-1… This is a small town and they don’t get European Championship games for their team like almost ever. It’s almost like a bioweapon was deliberately set off in Bergamo, although this is not at all a possibility, the intensity of the disease is like a bomb went off.
So what does this mean for the U.S. and civilization as a whole? Well, it’s much worse than we all hoped at the beginning and the numbers are very solid now. Italy’s testing isn’t perfect, there are peculiarities with the demographics, the intensity of the initial outbreak appears extreme and perhaps even genetic factors are causing the deviation from S. Korea and China. That said, we have a very good understanding of the worst case for this virus if you’re only a week or two late in social distancing. No social distancing would look a lot worse. The US, France, Spain etc. situations are trending the same way as Italy, but all other countries have a head start. Again… were we late? Maybe a little but not by much. However any state/city etc. that is not at NYC or LA levels of lockdown are making a huge mistake. The slopes of the curves (deaths) for all have now been shown to be highly similar. The only difference will be that everyone else has a head start on Italy so we need to trust the scientists and the math. Take home message — Stay home as much as possible. Keep distancing. Be vigilant and ride this thing out. Better 6 ft apart than 6 ft under (hat tip to Cambridge, MA, “6 ft/ apart dancing guy” for the joke — he’s a live PSA. He’ll dance with you if you stay at the end of his 6 foot long stick). Remarkably, I strongly believe that when we get through the summer we will see that this social distancing has also had a positive effect on influenza deaths and other communicable diseases… Something to ponder.
China… sigh. If their numbers can be trusted then Italy may be the exception and China/S. Korea/Germany is the rule. Germany is simply way too early to make any conclusions although too many will and have already started speculating. Good at following shelter in place orders and just a highly efficient culture, more hospital beds… All doubtful. If Germany’s resistance continues then perhaps genetics are contributing to resistance/susceptibility or more likely Germany started quarantining early enough in their outbreak to snuff it (Like S. Korea). This is the most important fact. If we distance earlier we can snuff these things out. We always knew this. The question is when? Unfortunately, the Chinese Government literally fucked us all on the timing by hiding the disease for so long. The infection rates and death rates from China and S. Korea also led to a false sense of security since both countries contained the virus extremely well. As an expert, it is hard to reconcile China’s official death rate before they got this under control, however. I don’t care to speculate here on how a dictatorship could snuff out a nasty little bug like this so quickly and efficiently. I do believe their numbers now. Just not their peak.
Finally, this is a bit frustrating for scientists who have been in the field ~20 years and more. In my presentations which I gave 100’s of times over 2 decades, it always started with Diagnostics and Detection. Smart quarantining is more effective and much less costly than shutting down entire countries. We do need another test that I don’t hear anyone talking about urgently enough too. This is the test for whether you have been exposed to the virus and potentially have built up immunity. The current test only registers positive if you have live virus in you. Nearly 20 years ago I tried to propose a vision to the US government of private public partnerships in biomedicine similar to the types of partnerships with the Aerospace Industry… etc. We made great progress in some ways, but there was never enough money by a factor of 100-1000 (compared to weapon systems) and the big pharma and vaccine companies were also resistant since they didn’t need any DoD money. Take Home — We could have been much better prepared. However, the experts have already gamed this out so it’s now just a matter of execution and ramping up. We’ve learned a lot with the COVID19 pandemic too. There will be others in the future. Perhaps the most creative thing we can do as a civilization is figure out when and how we shut everything down and not crash the economy every time we need to do this.
On a personal note — I lived and worked in Italy for 4 years and had an office there for 17. My wife is Italian (we met there) and all of her family is there. I have many friends and colleagues there too. This isn’t just professional or scientific. This is personal. However, their black swan events may have saved a lot of lives. It’s a very emotional time for me despite my technical experience. We all were really hoping the curve would have flattened by now.