“So healthy people, if you’re healthy you will probably go through a process and you’ll be fine,” according to the President. “There’s no reason to panic at all.”
Except, perhaps, that we have become a decidedly unhealthy nation where “underlying conditions” are more the norm than the exception. Not all the conditions listed below may impact the severity of a COVID-19 infection. But with at least as many unknowns as knowns swirling around this disease, it is still too early to know for sure.
- Age has emerged a significant underlying condition as it is for many diseases, including flu. Roughly 70 million Americans are now age 60 or above, a tally that has increased dramatically in recent years as the massive Baby Boom generation officially enters codger-hood. The President and four Democratic presidential candidates are at least 70 years old, including the two front-runners. Some are closer to 80.
- Being male may be an underlying condition. The majority of the most serious cases in China, where COVID-19 first emerged, have been men—including the brave, whistleblower doctor in his 30s who literally gave his life trying to warn the world. However, it turns out most men in China smoke, while most women don’t, so their already-compromised lungs may have proved easier fodder for a pathogen that attacks the respiratory system.
- Slightly less than 14% of Americans over 18 smoke. That’s about 34 million people. Meanwhile vaping, a lung-shredding, addictive practice, has become popular over the last few years, especially among teenagers.
- According to the American Lung Association, more than 15 million Americans suffer from Chronic Obstructive Pulmonary Disease (COPD). Millions more may be undiagnosed. COPD is known to increase vulnerability to infection.
- An estimated 25 million American have asthma, including 8.4% of all American children. The stats have been rising for the last several decades across all age, sex and racial groups.
- The CDC reports that about 42% of American adults are obese. That’s more than 100 million overweight people. This is a 40% jump in the obesity rate over the last 20 years. And about 10%—10 million people—are classified as “severely obese.”
- Obesity is also an underlying condition for all sorts of other underlying conditions, including diabetes (30 million Americans, plus 70 million more with “pre-diabetes") and coronary heart disease, the leading cause of death in the US (~20 million Americans; 103 million with high blood pressure).
- Poverty is another kind of underlying condition. Many impoverished communities are “food deserts” where access to affordable, healthy food is difficult, so the bedrock of health—good nutrition—is almost impossible. Buildings, including homes and schools, are also more likely to have mold, bug and vermin issues, all of which have been linked to asthma.
- As medical care extends life-spans, most notably for cancer patients and people living with HIV / AIDS, the number of Americans who are immunosuppressed is on the rise, now estimated at about 3% of the adult population or about 10 million people.
- Pregnant women and people managing chronic illnesses such as Lupus, an auto-immune disorder, Lyme Disease, or allergies could also be considered to have underlying conditions.
- By rolling back nearly 100 Clean Air Act protections, this Administration has put us all at increased risk from a pathogen that targets lungs.
It is a thin line from “underlying” to “pre-existing” condition. If the Administration prevails in dismantling the Affordable Care Act, insurers will soon be able to deny coverage for anything they decide qualifies as “pre-existing.” Not only does this create a significant disincentive for those in need of medical attention, but it also comes at a cost to public health.
In a case that has drawn national attention, an American who had recently been working in China wound up with a $3,000 medical bill when he went to a Miami hospital to get tested for COVID-19 after he started to feel ill. The good news is he didn’t have the coronavirus. The bad news is he was diagnosed with flu. The worst news was that he had one of those high deductible, so-called “junk” insurance policies that have recently been made legal. Unless he can come up with three years worth of medical records proving that his flu wasn’t a pre-existing condition, the insurance company won’t cover any of the bill.
At least he had insurance. Those without insurance, or who can’t afford high co-pays and deductibles, or who may be illegal immigrants and are terrified at the prospect of risking deportation—or are related to illegal immigrants—won’t be rushing to get tested.
There is also no way to know at this point how the COVID-19 outbreak will factor into insurers’ calculations for pricing next year’s premiums. A significant cost hike would mean more people unable to afford even the most bare-bones insurance plans.
US healthcare, which ranks a dismal 37th in the world, is at odds with the very concept of public health. A highly contagious, potentially fatal pathogen for which there is as yet no cure or vaccine throws this into high relief.
COVID-19 is a great leveler, as likely to infect those with means as those without.
In the near term, testing for potential cases in US doesn’t really matter any more in terms of disease containment: The virus has been spreading for weeks and possibly months. It has now spread to at least 60 countries.
The roll out of the CDC’s diagnostic test was a spectacular series of fumbles. Not only was the test error-prone, but there weren’t nearly enough test kits to meet demand. Further undermining efforts at disease surveillance was a decision to limit testing only to those who had recently been in China or on an affected cruise ship.
Thanks to some clever genetic sleuthing we now know that the SARS CoV-2 virus that causes COVID-19 had been circulating in Washington state for perhaps as long as six weeks before the first, and as it turned out, fatal case was identified. According to government statistics, nearly 276,000 Americans traveled to China on business in 2019, and another 1.6 million visited as tourists. While SARS CoV-2 did not emerge until the very end of the year and in a limited geographic area (the city of Wuhan), it is possible that a few hundred, perhaps a few thousand, travelers were exposed and brought the virus home with them—months before any US public health surveillance protocols were put into effect. If the first cases appeared in the US just as the cold and flu season was ramping up, it would have been reasonable to chalk up those illnesses to colds or flu. No one was testing for COVID-19. Indeed, only a small fraction of flu patients get tested for flu. It is simply easier and cheaper to treat symptoms.
Compared to other countries, where testing has been both comprehensive and coordinated, the US response barely registers. No data also means no bad data, which in the politicized atmosphere of the White House might have been the point. Whether by design or incompetence, data that would have been critical for developing a proactive strategy to contain the outbreak wasn’t collected.
A few days ago data on how many tests have been given was removed without explanation from the government’s daily reporting sheet. Instead, only the number of cases that have tested positive is listed. This is a tiny subset of the whole, but allows officials to report that there are only x number of confirmed cases, which at best is misleading.
While many, including the Surgeon General, have pointed out the limitations of face masks for preventing the spread of the virus, it is possible that masks may have played a role in actually spreading the virus. Most people do not know how to properly dispose of a used mask (carefully, in a sealed plastic bag). For those infected—many of whom show no symptoms, yet can still shed virus—breathing into a mask could turn it into a fomite: an inanimate object capable of transmitting disease. SARS CoV-2 can survive on surfaces for days.
As an aside, one of the first modern cases of biological warfare involved fomites. In the 1760s, the British Army deliberately gave Native Americans blankets that had been used by smallpox patients. They knew the blankets were infectious, even if they didn’t understand why. (The development of the smallpox vaccine was still several decades in the future). But that didn’t stop them from turning a microbe into a weapon.
Given the contagiousness of COVID-19, it is possible that the mass use—or more to the point the mass misuse—of face masks could amplify an outbreak.
VACCINE: FUTURE FAIL?
It is hard to design a good vaccine. No vaccine is 100% effective. For example, this year’s flu vaccine is 50% effective against one strain and only 37% effective against a second strain. Doctors still recommend getting a flu shot because some protection is better than none.
SARS CoV-2, like the flu, is an RNA virus, which among other things means that it is prone to mutation. This makes the process of developing a vaccine a little like whack-a-mole. Just when you think you’ve got a good match to neutralize the virus, it changes.
Even when the vaccine is a good match, fine tuning the level of immune response is tricky. The lethality of COVID-19 is the result of an overly zealous immune response by the host. Scientists aren’t sure what kicks the immune systems of some patients into overdrive, nor can they identify who is most likely to have such a response. But for those people, a vaccine could prove fatal.
Further complicating matters: the blessing and curse of a natural “herd immunity,” which happens when enough people in a population are infected and develop antibodies. When a virus can’t find a host, it fades away. At least until it mutates.
Herd immunity may be a part, though only a small part, of the story of what’s happening in China, which has seen a dramatic reduction in the number of new cases. China’s aggressive, comprehensive campaign of viral containment has clearly been effective, if difficult to duplicate elsewhere.
Given the contagiousness of the SARS CoV-2, some epidemiologists predict that as much as 70% of the human population—billions of people—could become infected in the coming months and years. Unfortunately, we won’t know who is naturally immune and who isn’t; who needs a vaccine and who doesn’t. In between viral flare-ups, people might be less motivated to get a vaccine, especially if a co-pay is involved as it often is for seasonal flu shots.
The track record for coronavirus vaccines is sparse. Although there are hundreds of coronaviruses, only a handful infect humans—and until the emergence of SARS, they weren’t known for causing serious illness. Most coronaviruses target other species and there hasn’t been a need, or a market, for a vaccine to protect them. That is except for cats. Most of the time Feline Coronavirus (FCoV) is a fairly mild disease, but a mutation turns it into a fatal one: Feline Infectious Peritonitis (FIP). Scientists have been working an a cat vaccine for years, but so far have been unable to develop one that works reliably.
All of which is to say that the path for a SARS CoV-2 vaccine is full of challenges. It will take time and there will likely be many failures along the way. There are no guarantees it is even possible.
A FEW WORDS ABOUT BATS
The origin of SARS CoV-2 is likely from a bat, transmitted to humans through an unknown intermediary species (possibly a fish!). Bats have been the source of all kinds of viral threats that have emerged in recent years: SARS, MERS, Nipah, Marburg, Hendra. In fact just in terms of coronaviruses, bats have been found to harbor 200 different kinds, few of which seem to be making the bats sick. What’s going on?
There are two, dovetailing theories, both addressing the unique metabolic requirements of bats. When a bat takes wing, it requires so much energy that its temperature increases dramatically. In effect, the bat has a fever. To cope with the threat of literally burning up and burning out, bats evolved an amazing immune system that is able to generate a response without causing inflammation. Cells can also be physically walled off from pathogens, reducing the need for any response at all. This means that almost nothing makes a bat sick, which means that bats can live for a very long time, especially considering their size.
As a rule of thumb, every animal gets roughly the same number of lifetime heartbeats. Small animals such as mice whose hearts beat fast last only a couple of years, while the median age for African elephants whose hearts beat much more slowly is somewhere in the mid-50s. Bats are the rule-shattering Methuselahs of the animal kingdom: small animals that can keep going for decades.
The second theory focuses on the viruses in the bats. These pathogens evolved to withstand high temperatures and temperature fluctuations. In effect, they are extremophiles—just like microbes that evolved to thrive in hot springs.
This could provide an important insight into why the typical human immune response—fever and inflammation—may be not be effective against bat viruses. From a viral perspective, the heat feels like home. Turn up the temperature and they continue to thrive.
ADVICE & PERSPECTIVE
Most people infected with SARS CoV-2 will have what looks to the world to be a run-of-the-mill cold. Some won’t show any signs of infection. (It is worth noting that a significant number of people infected with flu are also asymptomatic. Infection and illness are two different things.)
What makes COVID-19 a global threat is the combination of its contagiousness and potential for devastating illness and death. About 14% of cases are characterized as severe and 5% as critical. Although the mortality rate is now expected to be less than 1%, that is still several times the mortality rate of flu (0.1%). Given the expected number of cases, which could run into the billions, that is a lot of sick people. A lot of death. A lot of heartbreak. A lot of loss.
In the near term, there are several things we can each do to minimize risk. Top of the list is washing hands regularly with soap for a minimum of 20 seconds. Cleanliness counts, especially on surfaces that are routinely touched, such as phones and tablets. When you feel the need to cough or sneeze, use a tissue if you can, or make like Dracula and cough or sneeze into your elbow. Wave hello rather than shake hands or kiss cheeks.
Eat healthy. Exercise. Try to get enough sleep. Spring is around the corner, so go outside and soak up some sunshine. If you smoke or vape, stop. Stop doing anything that could harm your lungs.
Listen to your mother.
In the long term, public health has to become a top priority. Imagine if all the money now being poured into the emergency response for COVID-19 had instead been poured into shoring up protections for clean water and air, expanding food and nutrition programs and building affordable housing. There would be more than money left over to increase funding for public education, support a living minimum wage and—this one is critical—universal health care.
Three more things:
- Stop skewing the rules to make unhealthy practices legal
- Reverse the hiring freeze at the CDC and fill 700 vacant positions immediately
- Increase funding for scientific research, including basic research
This is the foundation for a productive, prosperous, innovative, healthier, happier, more equitable and resilient society. This is what made America great in the first place. This is what built a robust middle class. Get it right and the stock market will take care of itself.
At the same time, there is an urgent need to better understand and appreciate our role as humans in the greater scheme of things. COVID-19 is a zoonotic disease, typically defined as an animal disease that somehow “jumps” into humans. But humans are animals, so perhaps it would be more accurate and useful to frame zoonoses as diseases that affect multiple species including humans. We are a part of Nature, not apart from Nature.
Once we see the world as an intricate, elegant web of connections, it is also easier to see the many costs of disruption. It has only been in the last 150 years that microbes circulating in wildlife populations (notably, most of the time not causing severe disease in their native hosts) have emerged as serious health threats to humans: SARS, MERS, Zika, Ebola, West Nile, COVID-19. One after another—and it isn’t hard to see why. Forest, grasslands, wetlands, streams, lakes, rivers, oceans—entire ecosystems have been disrupted and transformed at scale.
Every time an ecosystem is altered, old and new residents are thrust into unnaturally close proximity, with all sorts of ramifications. Every time a species goes extinct, its microbial fellow travelers either must find new hosts or die.
It would be a mistake to think that humans are the only victims of this great microbial mixing. Bees, frogs, snakes and even bats are battling devastating, new pathogens that threaten to wipe out entire populations. When West Nile first appeared on the North American scene twenty years ago, it was a scary disease for humans, but a devastating one for crows, with a mortality rate approaching 100%.
Livestock also face a continual onslaught of new and re-invigorated pathogens, the danger of which is amplified by their close living conditions. A disease can spread fast, especially in CAFOs (confined animal feeding operations). Pigs by the millions have had to be culled in China over the last several months in an effort to contain an outbreak of African Swine Fever. Cattle are beset by a broad range of bacterial and viral pathogens that include several tick-borne plagues, also parasites. Strains of highly pathogenic bird flu (avian influenza) present a near-constant threat to poultry.
Plants, both wild and agricultural, are also under constant disease threat: for example the re-emergence of wheat stem rust in Western Europe after 60 years, a devastating disease responsible for historical famines.
COVID-19 is part of a much larger, planet-wide story, a tragedy that we have largely brought upon ourselves.
“Disease is an outcome.”
—Milton Friend, wildlife biologist and founder of the National Wildlife Health Center
Many things have to go wrong to make a disease outbreak possible. COVID-19 didn’t simply happen. This pandemic was a very long time in the making.
Scientists have determined that 96% of the SARS CoV-2 genome is a dead-ringer for a bat virus, so the story begins in a bat. But at some point the virus left the bat for the wider world. Perhaps it escaped hidden in some guano that somehow came in contact with another species that it promptly infected. Perhaps the bat died, fell to the forest floor and the virus became a microbial bonus for whatever eventually ate the bat. Or maybe a very old bat simply lost its immune superpowers, got sick and sneezed.
Or maybe the bat took a bite out a piece of fruit, which fell into the shallows of the South China Sea, where it was nibbled by a fish, who picked up the virus wiggling around in bat saliva. This fish, complete with viable virus, was then eaten by another fish until somehow it ended up in a soldierfish where the virus promptly assimilated a 39-base insertion for a spike gene.
All of the above is conjecture (although saliva-kissed fruit was how Nipah virus got into pigs, who then passed it to humans). But there is an answer and it’s hiding in plain sight in the 4% of the viral genome that doesn’t match the bat version.
We may never know exactly how SARS CoV-2 found its way to the residents of Wuhan, China (most likely through a live animal market, but that has yet to be confirmed). But we do know what happened next:
- a doctor in China tried to warn authorities, but they were more concerned about starting a panic so forced him to write a retraction
- the outbreak started in November, 2019, months before any travel bans were put in place
- the virus circulated undetected in Washington State for weeks before the first case was diagnosed because no one was testing for it
- the CDC developed an error-prone test
- SARS CoV-2 spread to more than 80 countries
- the global economy is now in danger of recession
Clearly there is a lot that can—and is—being done to improve response. For example, BlueDot, a Canadian AI platform, picked up the first signs of what turned out to be COVID-19 back in December when it spotted an unusual cluster of pneumonia cases in Wuhan. That kind of early warning can make an enormous difference. It is so much easier—and exponentially cheaper—to contain a small, localized outbreak than a global pandemic.
Yet the underlying issue—the underlying condition—is the loss of biodiversity. Although rarely framed in these terms, that loss is a threat to public health. The specter of a million species on the brink of extinction shreds the “intricate, elegant web of connections” that took tens of millions of years of evolution to develop. And as go the insects, so go we. Our own future in the cross-hairs.
A rapidly changing climate is another factor altering ecosystem dynamics. The ticks that carry Lyme Disease can now survive northern winters with ease, while massive coral reefs bleach from the heat and intense bushfires wipe out everything in their path.
It is all of a piece: climate health, environmental health, animal health, plant health, our health.
Nature can be magnificently forgiving given a chance. An ecosystem can be restored. A farm using regenerative practices can bring fertility back to the soil. A city can create habitat by using native plants for landscaping. Birds, bees and butterflies reappear. Predators and prey are in better balance. Streams fill with fish. Life returns.
But the more we lose—the more we shred—the harder it is to get back to Eden.
Microbial mixing—the ease at which genes are shared among and between viruses, bacteria and genomes—is essential to the success of life on Earth. It is a mechanism of diversity that expands the ability of organisms big and small to adapt to changing conditions. Evolution would be a lot less brilliant —and certainly less speedy—without it. A full 8% of the human genome is viral DNA. The ancestors of the mitochondria that power every single plant and animal cell—so every single cell in our bodies—were either independent bacteria or from an evolutionary lineage that led to bacteria.
In Nature this mixing happens at a comparatively gentle pace, occurring at the edges of ecosystems (at every scale). But by cutting downs forests, turning wildlands into farmlands, poisoning soil microbiomes with fertilizers and pesticides, building cities that sprawl to the horizon, paving paradise into parking lots and highways and altering the course of rivers, humans have redrawn the boundaries. By developing ever-speedier modes of transport, creating "super organisms" through the overuse of antibiotics and genetic modification,and changing the planet's climate through a massive transfer of carbon into the air (acidifying oceans in the process), the once well-defined edges of ecosystems have dissolved. Barriers of time and space have collapsed and with them the protections they afforded.
We are still in the thick of the COVID-19 story, so the focus has to be on emergency response. But if we don’t step back, at least for a moment, to try to see the outbreak in the larger context of natural systems, we will continue to put ourselves in harm’s way. Disease may be an outcome. That does not mean it is inevitable.