I am struck by the need to find meaning in these troubled times. Times of great uncertainty. Times of massive global disruption. With the fear of a looming invisible threat. The emerging reality that the world was not only ill-prepared but ill-informed. Despite warnings of experts that a global pandemic was inevitable. Experts informed by their experience with other novel coronaviruses during SARS in 2003 with Toronto as its epicentre or MERS in 2012 in the Arabian peninsula. Despite the warnings of health experts including a warning from Johns Hopkins in October 2019 on the imminent threat of a coronavirus or the warning from Bill Gates in a 2015 TED Talk that the world is not prepared for the next pandemic.
To contemplate our path forward and beyond these dark days of a pandemic, it is important to understand how we have arrived here, learn from those who are fighting at the leading edge of this battle and plan for the eventual end game. Though uncertainty clouds every aspect of the process of planning the path forward, we can find deep meaning to help guide us through.
Lessons from Wuhan and Italy
After 6 weeks of a novel coronavirus, SARS-Cov2, wreaking havoc in Wuhan, the Chinese government enacted a complete lock down of the city with its population of 11 million. On January 23rd, 2 days before the Chinese new year, Beijing gave orders to lock down Wuhan and other cities in the province of Hubei. As the most extreme form of quarantine used in modern times, the enactment of these draconian policies seemed the only measure effective in flattening the curve on the deadly virus. But in these early days, Beijing gave little warning to the world as to what was to come.
It did not take long, however, for the virus to spread beyond Hubei across Asia and now the entire Globe. An estimated 5 million people left Wuhan prior to the lock down. Chinese tourists in Rome and later a repatriated Italian man from Wuhan reportedly brought the deadly viral infection to Europe and put Italy at the epicentre of what soon became the European COVID-19 Tsunami. The Lombardy region of Italy, with an aging population, was hit hard and fast and soon was flooded with critically ill patients with COVID-19, the disease caused by SARS-Cov2, overwhelming their healthcare system presenting with a severe viral pneumonia for which there is no treatment.
The Italians sounded the alarm but unfortunately the world was out of time. The carnage of Italy’s frontline with nearly 80 dead healthcare workers stands as a dire warning of what will become our future. Now other European countries are meeting the same fate. Neighbouring countries, like Spain and France, are battling to contain the impact as now in Italy there shines a glimmer of hope with recent reductions in their reported death rate. Evidence that the Italian’s extensive lockdown and country wide quarantine is working.
Across the Atlantic
But what will become of North America? Despite early warnings from Asia and Italy, we were blindsided by the impact of this viral threat. Although, the first known case of SARS-Cov2 in Canada was reported on March 5 in BC and on March 8 in Ontario it is most probable that the virus was circulating in our communities beforehand. A spike in patients reporting respiratory symptoms in late February with known travel risks suggests that COVID-19 was more likely causal to their illness than influenza, which seemed to be petering out by early February. Returning travellers in early March resulted in exponential increases and widespread infection such that by the end of March community spread accounted for most new cases. A State of Emergency was called across the country starting on March 17 in BC and by March 23 in Ontario with closures of schools, non-essential businesses and limits to public gatherings. Tightened stay at home measures, further business closures, punitive fines and increased police enforcement were announced on April 4th with a second province-wide Emergency alert.
The news south of the border is terrifying. The United States reports over 1,100 overnight deaths, the highest daily death rate of any nation thus far. And this is just the beginning.
Predicting the Path Forward
We are at a critical point in our fight against this viral threat. There are too many factors to properly model and predict the course of this pandemic. Visibility remains 3 days; yesterday, today and tomorrow. Caution must be applied when interpreting reported statistics and model-based predictions as inputs such as the reproduction rate, transmission rate and fatality rate may all be unreliable.
The reproduction rate of a virus -known as Ro (R naught)- is not only a biological feature of the pathogen (estimated for SARS-Cov2 as 2-2.5, higher than the seasonal flu at 1.3 but lower than measles at 12) but also highly influenced by environmental conditions (such as humidity and UV radiation) and human behaviour including the isolation of infected persons. With extreme quarantine measures, it may be possible to compress Ro helping to contain the contagion. But we must also understand how the virus is transmitted and its case fatality rate. These factors too are uncertain.
How can we calculate rates of transmissibility and fatality for a virus to which humanity has no established immunity and no available treatment. Without widespread population-based testing to understand how many of us are infected how can we accurately predict rates of infection or case fatality. Without wide-spread testing we cannot fully account for the risk of asymptomatic spread. The nature of transmission is important as well. Case reports from those who were in areas occupied hours earlier by individuals who had not yet reported symptoms but later fell ill, suggest a causal role of aerosol and surface spread of SARS-Cov2. Transmission of COVID-19 by aerosol and fomite spread of the virus from surfaces is suspected but not fully understood. Studies suggest transmission in aerosols may exist for up to 3 hours and on surfaces like plastic, copper and cardboard for hours to several days. Furthermore, viral shedding has been shown in the stool of infected persons up to 5-7 days beyond the resolution of their symptoms suggesting the role of fecal-oral transmission. Environmental controls and population based restrictions to manage these different modes of transmission are critical and must include hand hygiene, strict physical distancing, self-isolation and home quarantine. Success in navigating through this viral pandemic will depend on each country’s ability to quickly enact and enforce such measures. But is a global co-ordinated effort of this magnitude possible?
Measures of Hope
Let’s hope so. With contained spread, healthcare systems across the world may be better prepared to deal with the critically ill. By containing spread, we can supress the number of patients exhibiting severe symptoms of respiratory distress requiring intubation, ventilation and intensive care. Keeping our healthcare system from being overwhelmed by the critically ill will be key to containing the fatality rate. Ensuring we have sufficient resources and critical personal protective equipment to keep our front line healthcare workers safe.
There is hope in the numbers as to the success of measures enacted thus far. On April 2, Public Health Ontario provided pandemic predictions estimating that the quarantine measures already enacted have reduced the projected death toll from an estimated 100,000 to between 3,000 to 15,000 COVID-19 related deaths. There is reason to be hopeful and also to maintain compliance with tightening requirements of quarantine.
So what is the Endgame?
It is very unlikely that the virus extinguishes as rapidly as it has emerged and devastated the world. The risk of one new infection reigniting the fires is now established in areas like China and Singapore that are seeing resurgence after seemingly achieving containment and subsequent loosening of quarantine measures. Over the next 18 to 24 months it is estimated that 60 to 80% of the globe will be infected. The possibility of a lasting herd immunity of the infected and recovered population making them resistant to future reinfection and transmission is unclear. Furthermore, herd immunity as a strategy to win the war would come at a terrible cost with millions of lives lost and devastation to the healthcare systems of the world. The possibility that innovative strategies win the war is by far the most favourable but a ways off. While the race to a vaccine against SARS-COV2 is full steam ahead, its widespread availability to protect populations around the world seems far off.
As I reach to find meaning in a global pandemic, I am struck by the significance of traditions celebrated at this time. Reaching for hope and meaning, my family prepares to retell the story of a people fleeing slavery, escaping under the wrath of ten plagues. A people left to wait 40 days to receive their commandments only then to be left to wander another 40 years to eventually find a new beginning in a land of their own. Like the 40 days and nights of flooding in the time of Noah, the number 40 has much biblical significance representing a spiritual new beginning. Turning from biblical times to ancient times, we find historical connection as indeed it was in Italy that the 40 day quarantine was coined. The Italians, a people amongst the hardest hit by the pandemic, centuries ago used the term quarentina to describe a 40 day isolation period applied to arriving ships at the ports of Venice to reduce the spread of disease. And so here in 2020 (20+20), we can find meaning from various sources; through spiritual beliefs, traditions, symbolism in numbers, and our shared history. Regardless of the source of inspiration, may we each find meaning to help us through this challenging time. To bring purpose and a significance that stirs in us something deeper than does the nightly news. May this be a time marking a means not to an end, but rather to a new beginning.
Dr. Jennifer Pearlman
Dr. Pearlman is a medical doctor in Toronto, Canada. She is owner and Medical Director of PearlMD Rejuvenation a Precision Integative Medical Clinic offering expert medical care, leading technology and treatments to help patients achieve Ageless Vitality. Dr. Pearlman is an internationally recognized expert in Women’s health, hormones, aging and cosmetic medicine.