[Cross-posted from www.the-trench.org]
Book review: Debora MacKenzie, COVID-19: The Pandemic That Never Should Have Happened and How to Stop the Next One (New York: Hachette Books, 2020), 279p.
The book opens with the quote from a poster seen at the first March for Science on 22 April 2017: “Every disaster movie starts with someone ignoring a scientist”. My immediate thought: well, scientists may be clever, but they just cannot express their thoughts in a register that politicians and opinion shapers might understand. Another reflection replaced it instantaneously, this time on politicians: they are so ideological that if their teachings tell them to view everything through a square, then they will only see squares. Try to square a circle if the opposition solely looks at the world through circles. Compromise, if possible, may take policies forward, but maybe not in directions that raise resilience to catastrophes.
Debora MacKenzie is a scientist and a journalist for the New Scientist and other science publications since – to the best of my knowledge – the early 1980s. She is also an engaged writer with a knack for making complex things understandable to a broad audience. And her deep knowledge reaches far wider than the mere ‘science’ of things or processes. This makes COVID-19 so engaging. The book project may have started early in the spring; the contents draw on her many years of probing experts in many disciplines.
She has been onto the potential of epidemics and pandemics since the start of the century. The Severe Acute Respiratory Syndrome (SARS) crisis that began in China in 2002 and hit her country of origin, Canada, badly is seared in her memory. She wondered whether an outbreak on the scale of ‘svarta döden’ (as the Swedes began calling the Great Pestilence of the mid-1300s in the 15th century) might recur; whether mortality might reach somewhere between 33% and 50% again; and what social, economic, and political factors contributed to the pandemic’s severity. Similar questions guide her investigation into COVID-19. Unsurprisingly, the narrative takes us back many years, even decades before the new coronavirus infected people in China. That story differs greatly from those politicians, experts, opinion shapers and other pundits like to feed us.
The perfect storm
In his book ‘The Perfect Storm’ Sebastian Junger recreates the final moments of a fishing boat out into the Atlantic Ocean when a massive cyclone hit the US east coast over the Halloween period in 1991. To many the title means a rare, unfolding event during which separate developments conspire to produce an aggravated outcome. Well, not quite. In the book, each contributing circumstance had been predicted or foretold, but the protagonists failed to act upon the warnings. In this sense, COVID-19 describes how many policy options, economic strategies, and social preferences over the past 3-4 decades made the preconditions for a perfect storm.
A first contributing element was a growing conviction in the 1960s that humanity had by and large vanquished disease. Technological and social optimism accompanied the view: vaccines were to defeat infections and prosperity contributed to the overall decline in disease. The formal declaration by the World Health Organisation (WHO) in May 1980 that the global immunisation programme had rid the smallpox scourge capped that optimism. The disposition, however, spawned two other trends whose impact greatly contributed to the difficulties in containing major epidemics in the 21st century.
Governments, especially in the more affluent societies, disinvested in public health. Internationally they reduced surveillance stations to detect outbreaks early or new sources of infection. The process also coincided with decolonisation, due to which surveillance outposts in spaces where new diseases often originate no longer provided advance warning of emerging health threats. From the early 1980s onwards, fiscal frugality to reduce national budget deficits combined with supply-side economics in industrialised countries eventually resulted in imposing budgetary constraints on international organisations like the WHO. This too affected surveillance and response capacities. Domestically, the same trends led into significant reductions of investments in health as a public good and the broad privatisation of health care. Governments likewise no longer saw value in maintaining development and stockpiling in drugs, vaccines, and diagnostics, leaving research and production decisions in the hands of private sector interests. Those governments also neglected to maintain a surge production capacity for critical goods if a major health emergency were to arise. After SARS had been overcome in 2003, investment in developing countermeasures halted lacking a market. MacKenzie argues that if public investment into vaccine research against the coronavirus had continued, then we may have had a head start in containing the COVID-19 crisis.
A second major contributing element are governments’ reluctance to heed warnings by scientists. For all the optimism that existed after the eradication of smallpox, by the end of the 1980s infectious disease experts were sounding the first alarm bells about emerging and re-emerging diseases. They also noted the zoonotic origin of many of the new health threats: as humans were increasingly destroying or penetrating the natural habitat for many species, multiple animal pathogens mutated to infect humans and then to become transmissible among humans. Their alarm signals did not prompt governments to raise their guards, meaning that when epidemics arrived, they had to rush measures, more often improvising than implementing preconceived policies. When opportunities presented themselves to re-evaluate political and economic choices, they ignored those early warning signals.
A third major strand MacKenzie identifies through the analysis of complex systems. In our globalised societies everything has become tightly and efficiently interconnected. This optimisation benefits profits. Therefore, supplies arrive ‘just-in-time’ and production sources are offshored to low-wage countries. One consequence, as most of us discovered during the COVID-19 crisis, is that most medication and medical equipment are manufactured in China (another thing health professionals had warned policy makers about several years earlier). Another upshot is the extreme rigidity in a highly optimised complex system. A shock gets transmitted through much of that system; if a link breaks down, the whole system suffers.
From a security perspective, no system should be optimised to the hilt. ‘Resilience’ and ‘redundancy’ are central concepts. Systems should be able to withstand maximal stresses. Should a link give way, then alternative options or routes must be available to immediately take over the failed link’s functions. The consequences of the rigidly organised complex system of international production, transport and delivery became almost instantaneously visible. With China in lock-down when the number of COVID cases exploded in Europe and the USA, much of the critical equipment such as face masks, disinfectant hand lotions or ventilators were lacking. Their unavailability from production sources – in China mostly – led to panicky decision-making and inept initial responses. Especially the hasty closing of borders contributed to further perturbations in the global system, affecting other economic sectors (including travel and tourism).
On the level of companies big and small, what was good for shareholders and balance sheets proved once more a liability in a crisis. Just like governments did not learn from the first SARS epidemic, companies ignored the lessons available to learn from the 2008 financial crisis. Governments this time stepped in with rescue packages costing hundreds of billions, if not trillions of Euros in taxpayer revenue to save the economy and employment. Big companies and smaller, family-owned businesses are failing or will crash once government-supported measures end and the COVID crisis is not yet over.
As MacKenzie wryly remarks, had governments been less willing to be economically or fiscally optimised and invested tens of billions of Euros in disease surveillance, preparedness and health as a public good over the years, then today they would be saving a multitude of that money now being expended as crisis response. And that thought does not even take the human and societal toll from lack of resilience and redundancy into account.
A ‘black swan’ event COVID-19 is not. MacKenzie illustrates throughout her book how scientists have been sounding alarms for many years. Both the outbreak and its consequences were foreseeable. The lack of preparation was a consequence of political and economic (so-called ‘rational’) decision-making, driven by ideological preferences.
The Wuhan lab, bats, and the USA
The author opens the fourth chapter with a curt answer to where Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) originated: ‘The COVID-19 virus comes from bats’. To emphasise the point, she adds: ‘So did SARS. So do MERS, Ebola, Marburg, Nipah, Hendra, and Lassa viruses.’ The bigger point: We need not look for exotic explanations about the beginning of COVID-19, such as a genetically engineered pathogen or an agent that escaped from a laboratory. She also gives short shrift to the idea that civets or pangolins at a wet market might have transmitted the virus to humans. When Chinese scientists, most from Wuhan where the outbreak was raging, summarised their work in late January 2020, they confirmed their finding that SARS-like coronaviruses had their natural reservoir in bats and that several among them had the potential to infect humans. The virus killing people in the city was 96 percent identical to one found in bats and uses the same cellular receptor. The SARS-like virus in pangolins is much more different.
The Wuhan Institute of Virology has played a key role in this monitoring of bats and research. Not in the sense of biological weapons research or a major biosafety incident as many press reports and commentators have suggested. Whether the wet market played any role in the outbreak still needs to be determined. However, as MacKenzie points out, many locals and bats interact in several ways with each other. Bats on the traditional Chinese menu are the larger fruit bats rather than the much smaller insect-eating horseshoe bats, which are host to SARS-like corona viruses. Therefore, traditional medicine may play a much larger role. Horseshoe bats’ faeces are used in products to treat several conditions due to the high Vitamin A content. The list of afflictions includes eye disorders. Researchers have confirmed coronaviruses in fresh horseshoe bat droppings. Drying such faeces might kill most, but not all pathogens present. The eye has receptors onto which SARS-CoV-2 latches itself, and research suggests that the virus may be persistent there. Practitioners of traditional Chinese medicine recommend the application of a water solution directly to the eye. It is therefore possible that the eye may have been an important route of infection. Dried bodies of the horseshoe bat are also a traditional remedy against coughs. Impoverished people catch horseshoe bats and collect their droppings, which may have created other routes through which humans might have contracted COVID. The faeces are also applied as an agricultural fertiliser.
Shortly after the SARS outbreak in China the Wuhan Institute of Virology began searching for the virus in nature. Right from the start the scientists considered bats (and their products in food and medicine sold on markets) as reservoirs for coronaviruses and mapped out the genetic diversity of the virus and how they attacked cells.
The Chinese researchers, however, did not work alone. They partnered with other initiatives, including from the USA. The PREDICT programme of the US Agency for International Development had set up local labs and surveillance in China and other countries with infectious disease hotspots. Their work included, among other things, detection of coronaviruses. A team from the EcoHealth Alliance, a PREDICT partner, isolated a live SARS virus that could infect both bat and human cells. It triggered an immediate immune response in people who had suffered SARS in 2003. After fourteen years, in 2017, they established the provenance of the SARS virus from bats as a scientific fact.
PREDICT also found that several coronaviruses were on the verge of human infection, meaning they did not require the intermediary of another animal species or much additional adaptation to cause illness. MacKenzie writes this knowledge was already available seven years ago and had been reported to a meeting on emerging diseases in Vienna in 2016. It was also noted that the new virus type might avoid experimental SARS vaccines.
From this the USA not only had the scientific data to understand the risks posed by novel types of coronaviruses, but also knew the activities in the Wuhan Institute of Virology. But the Trump administration shuttered the pandemic monitoring programme. Funding ended in 2019 and activities stopped in September after the money had run out. (It received an emergency extension for six months, starting in April 2020.) This followed on earlier actions that reduced the US Centers for Disease Prevention’s presence in China from 47 to 14 staff members since January 2017, downgrading monitoring capacity. Disease surveillance and early warning – at least for the USA – could not have been interrupted at a more critical moment.
A perfect storm just does not care about conspiracy theories, disinformation campaigns or alternative facts. It just takes place.
A sobering analysis
Debora MacKenzie presents us with sobering analysis of how an outbreak that infectious disease experts had been expecting for some years could turn into a global pandemic. Decisions made for political, ideological and economic reasons over the past four decades – some specifically relating to public health and infectious disease surveillance; other ones to how an increasingly interconnected, globalising society was organising itself – created the preconditions for the fast spread of SARS-CoV-2.
She also discusses many decisions by different actors once the outbreak had begun. These have been less the subject of the present review, but they were equally consequential. We can think of the refusal of lower and mid-level bureaucrats in China to transmit early reports of victims to the central government. There were the early actions by Chinese authorities to limit surveillance and containment only to people who had travelled to Wuhan; an error many governments in Europe and especially the USA repeated by initially focussing on persons coming out of China. As MacKenzie discusses, the first reflex (as seen in so many past pandemics) to blame foreigners produced measures that exacerbated the spread of the virus.
While the author introduces the reader to the basic science behind the COVID-19 pandemic (and actually makes the effort to explain terms and concepts in an easily digestible way), her broad knowledge of the ways social dynamics shape science and her long experience as a science journalist have yielded a most valuable book on how to understand current events. The book comes early in the pandemic and certain questions remain open. For sure, other sociological and political research questions rest to be formulated and answered.
Through her fluent writing and ease of explaining complex issues, she not only captivates the reader (it is difficult to put the book aside once having started to read it), but also helps her or him to make sense of an existential crisis many people alive today have not yet experienced before.