Reading science fiction like it matters since 1989.
Introduction
Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky.—Albert Camus, The Plague, 1948.
COVID-19 is currently a global pandemic. A pandemic is a disease outbreak that is prevalent over a wide area, from a group of countries to the entire world. The current pandemic disease, COVID-19, is caused by a novel coronavirus, SARS-CoV-2. The global spread is following an approximately exponential curve: it took 67 days to reach the first 100,000 cases; 11 more days to reach 200,000; and just 4 more to reach 300,000 cases. This virus’s deadliness lies in its stealth, spreading silently with an incubation period of weeks. It kills slowly, weeks after infection (Chen et al., Ferguson et al.).
This essay will briefly review the literature vis-à-vis epidemic disease in myth, in literature, and in science fiction. Real-life pandemic preparations will be outlined. The current pandemic will also be reviewed both from a local (the author’s country of origin, Malta) and from the global health and mortality perspectives. Economic consequences will also be briefly discussed. Despite preparations at national, international, and global levels, and despite cautionary tales copiously meted out by virologists, epidemiologists, and science-fiction authors, humanity has failed miserably in containing loss and maintaining quality of life during this evolving human tragedy. Indeed, it is almost as if we are in a dystopian science fiction novel with no resolution (a là typical science-fictional closure with a [usually] happy ending) in sight.
Legend, Myth, and Antiquity
Girard has noted that in myth and legend, plagues induce chaos in society, eliminate wealth, and elide or eliminate social classes. Such events were sent by the gods and terminated by the gods. This is echoed in the Bible, the most famous examples being the Ten Plagues of Egypt inflicted by Yahweh in order to force the Exodus; while some of these were bizarre events (the Nile turning to blood), many were pestilential.
Hippocrates (c. 370–460 bce), the father of modern medicine, was fascinated by the nature of infections, hygiene,, and epidemiology. His writings included an extensive assessment of the symptoms and spread of epidemics (Pappas). In Asia around two millennia ago the Inner Canon of the Yellow Emperor (c. 200 bce) took note of periods when everyone was infected with symptoms that were similar regardless of their age and said the most important way to dampen epidemics was to reduce the circulation of populations (Lu).
The unknown and presumed divine nature of epidemics led to Europeans beseeching St. Sebastian or (the appropriately named) St. Corona for intercession with God. Other religions also implored their respective deities, with South Asian texts such as the Sadhanamala advising offerings to Parnasavari, an enlightened being in Buddhism associated with deliverance from epidemic diseases. During the Black Death, Arabic texts recommended the recitation of verses pertaining to the life of Muhammad, and some European Christian sects took to marching barefoot in hair shirts while flagellating themselves and simultaneously asking for forgiveness and protection from God (Pappas).
Fiction and Science Fiction
Mainstream literature written by non-science-fiction writers tends to emphasize the ineffectiveness of medicine. Mary Wollstonecraft Shelley’s The Last Man (1826) introduced a plot device that would eventually be reused by a string of writers: an apocalyptic plague that threatens to destroy humanity. The medical field appears powerless to help out except to provide hospitals for the terminally ill. The infectious agent in question is not specified but were it was yellow fever or plague, the epidemic displayed a virulence previously unfelt. Over the seven-year course of the epidemic, there is only one survivor: the narrator.
Similarly and more recently, in Albert Camus’s La Peste, not only are doctors completely incapable of arresting an outbreak of bubonic plague in Algerian Oran, but incredibly, they take considerable time to realize that a fatal epidemic is sweeping their city and to organize quarantine measures. This delay was despite rats dying bizarrely and en masse, followed by large numbers of the populace coming down with obvious signs of bubonic plague. Camus also emphasizes that nature is hostile or at best indifferent to humanity and suffering.
A search using the term [epidemic] or [epidemics] on The Internet Speculative Fiction Database yielded 27 narratives, and a few will be discussed. In Earth Abides, George R. Stewart postulated a novel virus, “some new and unknown disease of unparalleled rapidity,” a kind of super-measles. The protagonist finds himself inadvertently immune due to a snake bite while more than 90% of the population dies. This was the first novel to implicate rapid global spread (just two weeks) aided by airplane travel to appear almost simultaneously in every center of civilization, outrunning all attempts at quarantine—precisely the current scenario.
Epidemics have also been engineered in science fiction as forms of biological warfare. For example, Stephen King’s The Stand introduces a military-engineered superflu with a 100% communicability and 99.4% fatality. The epidemic spreads rapidly since the U.S. government refuses to acknowledge the existence of the virus and its inability to contain it—shades of Wuhan Province earlier this year. The Georgia flu, which explodes like a neutron bomb over the surface of the earth in Emily St. John Mandel’s Station Eleven, has a 99.99% communicability and fatality, and the narrative describes precisely what we have witnessed in recent days: panic buying, locking oneself away, and even looting.
Movies have also demonstrated the possible outcomes of a pandemic, and an early example is The Andromeda Strain (1971, based on Michael Crichton’s 1969 novel). However, more plausible and prescient depictions include Contagion (2011), wherein a bat drops a piece of a fruit, which is eaten by a pig. That pig is then slaughtered for consumption, and a woman who eats it is infected. When she returns to Minnesota from Hong Kong, she becomes patient zero and dies as the disease spreads widely despite quarantines and the breakdown of the rule of law.
Pandemic Preparedness
Pandemics are diseases waiting to unfold. They are typically zoonoses—human infections of animal origin—and political and economic forces have increased the risks of these events. Industrial-scale farming in China (with significant foreign investment) has marginalized millions of smallholder farmers, forcing their shift into the market for more exotic species that were formerly eaten only for subsistence. Geographically, industrial-scale farming in China has taken up prime land forcing these smallholders closer to nonarable zones such as forests in proximity to bats, known reservoirs for coronaviruses. The holes in the Swiss cheese model align: bat viruses through intermediate mammalian hosts such as pangolins and thence into humans. A similar scenario has also played out several times over the decades; influenza pandemics repeatedly arise from poultry and pig factory farms abounding globally (Morens and Taubenberger).
Intensive logging, mining, road building, and rapid urbanization exacerbate the situation, also globally. We have created a single, human-dominated ecosystem that serves as a playground for the host switching of animal viruses, resulting in the emergence of local, devastating diseases such as Ebola and Zika viruses but also occasional global pandemics (Morens and Taubenberger).
The U.S. intelligence community in its annual worldwide threat assessment warned almost us annually from 2009 to 2014 of the devastating consequences of a viral pandemic:
Health security threats arise unpredictably from ... the emergence and spread of new or reemerging microbes; the globalization of travel and the food supply.... Infectious diseases, whether naturally caused, intentionally produced, or accidentally released, are still among the foremost health security threats. A more crowded and interconnected world is increasing the opportunities for human, animal, or zoonotic diseases to emerge and spread globally.... Human and livestock population growth results in increased human and animal intermingling and hastens crossover of diseases from one population to the other. No one can predict which pathogen will be the next to spread to humans or when or where this will occur. However, humans remain vulnerable, especially when a pathogen with the potential to cause a pandemic emerges.... If ... influenza or any other novel respiratory pathogen that kills or incapacitates more than 1 percent of its victims were to become easily transmissible, the outcome would be among the most disruptive events possible. Uncontrolled, such an outbreak would result in a global pandemic with suffering and death spreading globally in fewer than six months and would persist for approximately two years. (Clapper 11–12)
The medical community has also frequently warned of the need
to create a preparedness plan for Disease X. Disease X is caused by Pathogen X, an infectious agent that is not currently known to cause human disease, but an aetiologic agent of a future outbreak with epidemic or pandemic potential. We have identified crucial areas for acceleration in medical countermeasure product development and international coordination. We have also reviewed novel platforms and process improvements related to manufacturing, which could revolutionize the response to the next pandemic. Finally, we created several coordination and engagement guides. These guides range from the rational design of an intervention target product profile, to the key facets of vaccine and therapeutic development, to accelerated manufacturing and regulatory mechanisms. (Simpson et al.)
These warnings have not only been enshrined in medical papers or intelligence reports. They have been popularized by public talks, including TED Talks such as “Help Me Stop Pandemics” in 2006 by Larry Brilliant, an American epidemiologist who helped eradicate smallpox and served as a consultant for the 2011 film Contagion. He averred that a pandemic would have almost unthinkable consequences, including millions of deaths and a global economic depression.
Additional prominent figures have reiterated this possibility, including Bill Gates, who noted on his blog in January 2010 that “the real story isn’t how bad H1N1 [influenza] was. The real story is that we are lucky it wasn’t worse because we were almost completely unprepared for it.” He called for investment in better capabilities to track and manage a deadly epidemic because more epidemics will come in the decades ahead and there is no guarantee we will be lucky next time (Toussaint).
Gates also in a 2015 TED Talk, “The Next Outbreak? We’re Not Ready,” stated that “if anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus rather than a war.... [Y]ou can have a virus where people feel well enough while they’re infectious that they get on a plane or they go to a market.” In a BBC interview in 2016, Gates said he frequently crosses his fingers against the possibility that some epidemic like a big flu comes along in the next 10 years. Again, at the Munich Security Conference in 2017, he noted that our worlds are more tightly linked than most people realize and that epidemiologists reiterate that
a fast-moving airborne pathogen could kill more than 30 million people in less than a year, and that this could occur in the next 10 to 15 years. I view the threat of deadly pandemics right up there with nuclear war and climate change.... Getting ready for a global pandemic is every bit as important as nuclear deterrence and avoiding a climate catastrophe. (Toussaint)
Once more, at the Massachusetts Medical Society’s annual Shattuck Lecture in April 2018, Gates noted that while life has kept getting better for most of the world, “There is one area, though, where the world isn’t making much progress, and that’s pandemic preparedness ... because if history has taught us anything, it’s that there will be another deadly global pandemic ... The world needs to prepare for pandemics the way the military prepares for war.” Indeed, the Bill & Melinda Gates Foundation has funded multiple grants and research programs geared toward developing new vaccines to prevent pandemic influenza and has invested in the Coalition for Epidemic Preparedness Innovations, an international coalition that launched at Davos in 2017. Gates had even laid out a master plan to stop the next outbreak in its tracks (Toussaint).
Pandemic preparedness plans were also primed by epidemiologists and virologists who were equally strident (if more scientific) in their admonitions:
Pandemics, whether mild, moderate, or severe, affect a large proportion of the population and require a multisectoral response over several months or even years. For this reason, countries develop plans describing their strategies for responding to a pandemic supported by operational plans at national and subnational levels. Preparing for an influenza pandemic is a continuous process of planning, exercising, revising, and translating into action national and subnational pandemic preparedness and response plans. A pandemic plan is thus a living document which is reviewed at intervals and revised if there is a change in global guidance or evidence-base; lessons learned from a pandemic, an exercise, or other relevant outbreak; or changes to national or international legislation related to communicable disease prevention and control. (ECDC)
Documents on websites of the ECDC, CDC, and WHO are replete with similarly worded and identical content (cf. ECDC, CDC, and WHO documents in the bibliography).
Malta Hospital Admission and Mortality Extrapolations
Malta, one of the smallest countries in the world, is a small archipelago in the center of the Mediterranean Sea with a total population of circa 492,000, a land area of 316 km², and the seventh-highest population density in the world. There is only one hospital with intensive care facilities (Mater Dei Hospital) along with a few other smaller facilities and private hospitals. The government of Malta has instituted an escalating series of steps that attempt to slow down COVID-19 infection rates in the hope that the Health Service will not be overwhelmed by the sheer number of severe cases as was the case in Northern Italy in recent days (Remuzzi and Remuzzi). Cognizant of the virus’s propensity to cause severe pneumonias, the country escalated its intensive-care ventilator capacity from 20 to potentially 100. A World Health Organization (WHO) report based on the Chinese experience estimated that circa
• 14% of infected cases are severe and require hospitalization.
• 5% of infected cases are very severe and require intensive care admission, mostly for ventilation with mean length of stay in intensive care of 10 days (Ferguson et al.).
• 2-4% of infected die (WHO).
Assuming infections continue to increase (whatever the rate) with patients requiring ventilation in a steady-state situation, if mean length of stay on ventilator is 10 days, and 100 ventilators are available and fully utilized, then each day, 10 patients come off ventilation (recovery or death). Since intensive care cases represent 5% of total infections, a simple proportion calculation shows that if local rates are as quoted by WHO and Ferguson, when daily infections exceed 200, there will not be enough ventilators to cope with demand as these will exceed 10 daily intensive care admissions, i.e., more than 70 new ventilator cases per week.
Figure 1 demonstrates overall potential total population infection rates (20, 40, 60, and 80% scenarios over a 14-week period). Totals are averaged for a week. Calculations are based on a population estimate of 492,000. It must be reiterated that these are best guesses and estimates that preclude the discovery of effective treatment and/or vaccination (Grech, “Covid”).
| Infected % | 20 | 40 | 60 | 80 |
|---|---|---|---|---|
| Infected | 98,400 | 196,800 | 295,200 | 393,600 |
| In hospital | 13,776 | 27,552 | 41,328 | 55,104 |
| Hospital per week | 984 1,968 | 2,952 | 3,936 | |
| In ICU | 4,920 | 9,840 | 14,760 | 19,680 |
| ICU per week | 351 | 703 | 1,054 | 1,406 |
| Dead | 3,936 | 7,872 | 11,808 | 15,744 |
| Dead per week | 281 | 562 | 843 | 1125 |
Figure 1: Infection and Mortality prejections for Malta
Global Mortality Extrapolations
Figure 2 shows estimates of potential deaths from COVID-19 using available data and current observations. There is naturally uncertainty over many of values ascribed but where in doubt, more conservative numbers have been assigned.
Continent 1 is Asia. China may have contained the disease and has been assigned a potential infection rate of 10% with normal mortality of 4%. The rest of Asia is assumed to become up to 80% infected, with 10% mortality due to healthcare services being overwhelmed.
Continent 2 is Africa, which is assumed to behave like Asia other than China.
Continent 3 is Europe, which has so far shown overall too few and too late responses to the disease. For this reason, Europe has been assigned a 60% overall infection rate and a (perhaps) optimistic 4% normal mortality.
Continent 4 is North America. The United States has reacted very poorly to date, and hospitals are already filling up. This country also has issues pertaining to insurance and undocumented immigrants, and for this reason, a 10% mortality has been assigned in anticipation of healthcare services becoming overwhelmed. Canada has also acted late and the same conditions have been applied. For Mexico, it has been assumed that physical distancing strictures will be at least as difficult to enforce as in Europe, in the setting of a poorer healthcare system.
Continent 5 is South America, which has somewhat arbitrarily been assigned a 60% infection rate.
Continent 6 is Oceania (including Australia). The population here has already responded poorly to physical distancing measures, so a 60% infection rate has been assigned to this region with a normal mortality rate.
In the absence of the speedy breakthrough of a successful treatment or the discovery of an effective vaccine that can be mass produced and widely distributed, this pandemic may cause close to half a billion deaths, i.e., 6% of the global population. It must be reiterated that these are estimates in the absence of the discovery of effective treatment and/or vaccination (Grech, “Unknown”).
| Cont. | Total Population | Inf. % | Number Infected | Mor. % | Number Dead | |
|---|---|---|---|---|---|---|
| 1 | India | 1,339,000,000 | 80 | 1,071,200,000 | 10 | 107,120,000 |
| 1 | China | 1,386,000,000 | 10 | 138,600,000 | 4 | 5,544,000 |
| 1 | Rest | 1,856,757,408 | 80 | 1,485,405,926 | 10 | 148,540,593 |
| 2 | Africa | 1,216,130,000 | 80 | 972,904,000 | 10 | 97,290,400 |
| 3 | Europe | 738,849,000 | 60 | 443,309,400 | 4 | 17,732,376 |
| 4 | USA | 327,096,265 | 60 | 196,257,759 | 10 | 19,625,776 |
| 4 | Canada | 37,064,562 | 60 | 22,238,737 | 10 | 2,223,874 |
| 4 | Mexico | 126,190,788 | 80 | 100,952,630 | 10 | 10,095,263 | 4 | Rest | 88,672,385 | 60 | 53,203,431 | 10 | 5,320,343 |
| 5 | South America | 422,535,000 | 60 | 253,521,000 | 10 | 25,352,100 |
| 6 | Oceania | 38,304,000 | 60 | 22,982,400 | 4 | 919,296 |
| Totals | 7,576,599,408 | 62% | 4,760,575,284 | 6% | 439,764,020 |
Figure 2: Infection and Mortality projections for the world
Known or Unknown Unknowns?
The Roman poet Juvenal (first/second century ce) despaired of finding a wife with his desired qualities, averring that such a woman was rara avis in terris, nigroque simillima cygno—“in this world a rare bird, very much like a black swan.” For the next two millennia, this term was used to refer to the mythical—but a species of black swans was discovered in Australia in 1697. The expression thus came to refer to a rare and unknowable event, a term formalized in economic theory by the American economist Frank Knight (1885–1972): There are things we know that we don’t know—the known unknowns. And there are unknown unknowns: the things we do not yet know that we do not know. These forms of risks were popularized by the economist Nassim Taleb this century. Based on what has been shown to date, the unfolding events are arguably known (not unknown) unknowns, and the unfolding disaster could have been averted in whole or in part.
Systems Failures
This section reads like a science fiction novel—how things went wrong. COVID-19 is a slow-motion disaster, fueled by a litany of incorrect decisions by various authorities. Lack of information informed the debacle, and the ultimate lacuna was unavailability of testing, which would have instantly revealed the state of play.
The first known cases centered at a seafood market in Wuhan, China, a city of 11 million—and, significantly, a transportation hub. The initial four cases of a new kind of viral pneumonia became dozens by the end of December (Ding et al.). The true size of the outbreak is estimated as at least 1000 cases, with each person infecting around three more. Even a perfect response might not have worked. However, Chinese officials did not inform the public, and they alerted the World Health Organization with a reassuring statement on 31 December: the disease is preventable and controllable. The timing was appalling, with hundreds of millions about to return to their hometowns for the Lunar New Year (Wu et al.).
At least 175,000 people left Wuhan just on January 1. By the time China acknowledged human-to-human transmission on 21 January, outbreaks had seeded in Beijing, Shanghai, and other major cities. Two days later, Wuhan was locked down, and many cities followed in the next weeks. Travel across China nearly stopped, but international travel continued, thousands flying out of Wuhan to cities all over the globe. Over 900 people went to New York on average every month. It is thought that about 85% of infected travelers went undetected, but they were contagious. By 1 March, thousands of cases were reported in Italy, Iran, and South Korea. By this time, the virus had settled in Seattle, in New York City, and across the United States (Wu et al.).
In January, Trevor Bedford, an American expert on the evolution and infectiousness of viruses, observed that the genomes of the virus found in various parts of China, and then in Thailand, showed clear signs of person-to-person transfer. The virus was not contained in China anymore, implying that it easily spread from person to person and was highly contagious. He alerted every public health official, to no avail. And yet, this was the moment that virologists and epidemiologists had spent years dreading and preparing for. Virtually all countries have pandemic-preparedness plans (Madrigal and Meyer).
Had this information been known, systems prepared over decades of pandemic planning would have swung into action, containing the illness and saving lives. The USA was further plagued by malfunctioning CDC testing kits, and the Food and Drug Administration held up tests made by independent labs. When community transmission was established, the initially restrictive rules allowed the scarce tests to be used only on patients who had traveled internationally or who had been exposed to a known case. The number infected doubled every six days. Without testing, the only way to estimate the severity of the epidemic was by counting the dead, and by the first death, at the end of February 2020, it was too late to contain the disease in the States (Madrigal and Meyer).
Pandemic preparedness plans had gamed out all potential scenarios including closing schools for months, social distancing, curfews, and more, but the algorithms were based on a test that would reveal and monitor the situation in real time before it spread and was too late to control. In short, these plans depended on that all-important public-health approach known as surveillance (Madrigal and Meyer). This was not available, and quite a few countries continue to lag in this at the time of writing.
At the start of February, Bedford believes, the U.S. had circa 430 infections; if so, up to a quarter of a million are infected by now. On 26 February, the CDC confirmed that community transmission had begun among Americans who had not travelled abroad or encountered a confirmed case. Viral studies from different areas showed that genomes were too similar to have arrived in the US at different times from different people, but they were also too varied to have arrived recently. On 7 March, as the severity of the outbreak in Seattle was becoming evident, large public events continued. For example, more than 30,000 people attended a Seattle Sounders game that night (Madrigal and Meyer).
The situation is out of hand with Louisiana now a hot spot, probably due to widespread infection during Mardi Gras, a week long, city wide celebration in crowded living rooms, ballrooms, and city streets which this year culminated on 25 February (Reckdahl, Robertson, and Fausset).
The Imperial College Report by Ferguson and colleagues estimated that unmitigated, deaths would reach half a million in the United Kingdom and exceed a million in the States. Mitigated (ny mild measures), UK mortality was estimated at half that number, and with full suppression (the current attempted course of action), deaths would be lower than 20,000. Many deaths in the former two scenarios would be due to severely ill COVID-19 patients who could not be receive breathing assistance simply due to insufficient ventilators (demand outstripping supply by a factor of 8:1), along with a breakdown in ordinary healthcare as hospitals are overwhelmed. The ability of health services to cope depends entirely on how well people observe lockdown measures.
Poor leadership has not helped, and Bergamo, Italy, where the outbreak has devastated the healthcare system, is just the forerunner (Giwa). In the States similar scenarios will play out, and as the
pandemic intensifies, shortages of ventilators have occurred in Italy and are likely imminent in parts of the US. In ordinary clinical circumstances, all patients in need of mechanical ventilation because of potentially reversible conditions receive it, unless they or their surrogates decline. However, there are mounting concerns in many countries that this will not be possible and that patients who otherwise would likely survive if they received ventilator support will die because no ventilator is available. In this type of public-health emergency, the ethical obligation of physicians to prioritize the well-being of individual patients may be overridden by public health policies that prioritize doing the greatest good for the greatest number of patients. (White and Bernard)
Pandemic Termination
This pandemic may eventually burn itself out if enough individuals contract and survive the disease, providing “herd immunity.” It is also possible, albeit unlikely, that the disease might be affected by climatic conditions, such as in Philadelphia in 1793 when an outbreak of yellow fever was terminated by cold weather that killed the disease-carrying mosquitoes (Eckert). Other relief from the current pandemic could come from a tight lockdown—imposition of quarantine, or similar practices that reduce the spread of infection. Or it could be checked or even eliminated with the development of medical interventions such as effective vaccines or antivirals.
Economic Consequences
The economic risks of a severe pandemic have been estimated at $3 trillion, a global threat to poverty with the poorest nations faring worst (Contributing to One World, One Health, 2008). Furthermore, the challenge for governments around the world will be to manage interventions so that the recession that is now inevitable is not significantly worse than that following the 2007–2009 financial crash (Thomas). There is a clear link between gross domestic product (GDP) and life expectancy. This is multifactorial and partly because wealthier countries are able to spend more on healthcare, safety, and environmental regulations. A reduction in GDP can thus be used to estimate the health effects on a population. This is not to say that lives can be traded for money but that money can save lives. The cost of controlling a pandemic and the resultant “high spending is likely to come up against ... GDP constraint, whereby the measure should not so decrease GDP per head that the national population loses more life as a result of the countermeasure than it gains” (Thomas 1). He estimates that letting the epidemic run its complete course would lead to the epidemic being over by September 2020, but such an approach would lead to a loss of life in the UK little less than that it suffered in the Second World War. For Thomas, the tipping point is a GDP fall of 6.4%, at which point more years of life will be lost due to recession than will be gained through beating the virus.
Conclusion
This is not an Aldissian cozy catastrophe. The media ensures that we can see all of the gory details: desolate public places, depressed and suffering humanity, patients in intensive care with invasive medical paraphernalia, exhausted and devastated healthcare workers, stacked coffins, and grieving relatives. We are unwillingly sharing a dystopian science-fiction scenario with no obvious short- or medium-term end to the inevitable deaths. Furthermore, the ensuing effects will result in significant economic hardship for all, especially those in developing countries. Moreover—at the risk of sounding melodramatic but with an extreme sense of realism since this author is a medical doctor with a special interest in epidemiology—our hospitals risk being plunged into chaos and plunged into the Middle Ages if the public does not do its part. Infection cannot occur in the absence of contact. The only way to mitigate these numbers is to apply physical distancing and take the precautions outlined by our public health specialists. Furthermore, there are no assurances that another pandemic by a different virus may not afflict us in future, especially if we do not learn the lessons that these three months have inflicted.
Victor Grech is a consultant cardiology pediatrician at Mater Dei Hospital, Malta.
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