“May you live in interesting times” has been said to be an English translation of a Chinese curse but is actually more likely apocryphal. In my 40 years of infectious disease training and practice encompassing emerging infections such as HIV/AIDS, toxic-shock syndrome, H1N1 influenza. Community-acquired MRSA, West Nile virus and SARS, nothing approaches the COVID-19 pandemic that we are all experiencing. I have my perspective as an infectious disease specialist and thriller author, but COVID-19 is affecting (hopefully not infecting!) all of us.

COVID-19 is a coronavirus and this is the first viral pandemic that is not due to an influenza virus. SARS was a more severe coronavirus infection that emerged in 2002 but never became pandemic. It is important to understand the reason. SARS coronavirus infection had a 10% mortality but essentially all infected patients were recognizably ill and were not infectious to others prior to onset of symptoms. This enabled effective contact tracing and quarantine that eventually snuffed out the outbreak after about 8,000 cases and almost 800 deaths. We were very lucky.

COVID-19 has only a 1-2% death rate but has proven impossible to contain because:

• Patients are infectious at least 2 days prior to any symptoms
• 30-60% of cases are mild or asymptomatic (but still infectious)
• Patients can shed virus for up to 2 weeks after symptoms resolve.

Widespread testing can tell you what’s going on in a community but we have not achieved that to date anywhere in the US and false negative test results can occur. Compounding the diagnostic dilemma is that the symptoms of COVID infection overlap with every other respiratory virus. Social distancing and masking will hopefully slow transmission through communities enough so that their hospitals will not be overwhelmed.

These Coronaviruses are very likely zoonoses (animal infections that are transmissible to humans). Big trouble arises when the infection is then easily transmitted human-to-human. All of the pandemics in history, whether bacterial or viral, have been zoonotic infections. I highly recommend the book “Spillover” by David Quammen, a science writer for National Geographic, for anyone interested in fascinating details of the animal origins of SARS, HIV, Ebola, influenza, as well as Hendra, Marburg and Nipah viruses, Q fever and more.

A few observations on the COVID pandemic:

The fear factor. Fear spread faster than the virus, although the virus managed to make its way around the world pretty darn fast. In the US, xenophobic incidents occurred, hoarders started hoarding and preppers accelerated their prepping well before the virus arrived. Why such fear over a virus that mainly threatens the elderly/immune-compromised patients similar to seasonal influenza (albeit with a 10-fold higher mortality)? I think it’s the newness and unpredictability combined with the lack of both a vaccine and an effective anti-viral drug treatment. Imagine the fear if the mortality were 10-20 or 50%!  Would the passengers on an infected cruise ship commandeer the lifeboats?

Another observation is how politics and governmental response can influence the course of the epidemic in a country. I’m amazed that China has kept COVID out of its other major cities; there are at least 5 bigger than Wuhan and all with populations in the 20-40 million range. China may yet see a second wave. In the US, all of our major cities are in for major trouble.  The basis is multifactorial but our leadership has a small government-big business mindset at a time when we need a big government-small business response. Enough said about politics.

It’s fascinating to see how a low-tech intervention—social distancing—can make a difference in mitigation of the outbreak. It remains to be seen how compliant society will remain if this drags on for months. It’s a twist that the internet and social media have been criticized as damaging to in-person social interaction yet now are the salvation of not only socialization but also many jobs in this time of social separation. 

So far, other than antiviral wipes, masks, and ventilators, nothing seems to be in short supply, except for toilet paper! Maybe someone has a good explanation for that phenomenon. I guarantee that standard bathroom tissue is not viricidal. Guns don’t seem to be in short supply – yet. Gun stores remain open as essential businesses and sales are brisk. I read that the FBI processed almost 4 million firearm background checks in March. One legacy of the COVID-19 pandemic will be that more Americans than ever will own guns. In open-carry states, will we see a gunfight over the last 12-pack of Charmin? I hope not. I worry more about the worsening mental stress of social isolation and loss of jobs/income resulting in more domestic violence, depression and suicide attempts. Guns in the home enable a higher rate of a lethal outcome.

COVID-19 deaths mainly occur in the elderly with co-morbid conditions such as diabetes, heart disease, emphysema, and cancer. Most young people are only mildly ill or not at all with some exceptions. The basis for severe infection in a young person is presumably genetic. What if … in the future, everyone knows their genetic profile and an untreatable virus comes along that is 100% fatal to the third of the population without a certain gene whereas those with the gene are chronic non-ill carriers? The carriers are infectious to those without the gene. I can envision plenty of conflict and ethical dilemmas in that scenario which is more real-world than any zombie apocalypse. The solution? Gene therapy or maybe stem cells?  Some of the gene carriers might just want nature to run its course.

COVID-19 is likely here to stay.  I think we will eventually return to hugs and kisses although maybe do more fist and elbow bumps in lieu of handshakes. We are, after all social, animals.

I expect that we will develop effective antivirals and a vaccine to help control it. It is also important to understand that the typical natural history of such events is that the human disease gets milder over time. This is from a combination of the micro-organism attenuating (becomes less virulent) and stronger immunity of the population. Evolutionary-wise it is not in the microbe’s best interest to kill its new host. Death is a generally a dead end for further transmission. When we run a “respiratory virus panel” on a nasopharyngeal swab taken from a patient, the secretions on the swab are tested for 14 viruses including 4 Coronavirus strains (229E, HKU1, NL63, and OC43) all of which only cause cold-type infection symptoms. It is certainly plausible that in the distant past one or more of these strains caused a severe respiratory COVID-like illness.

No question that when microbes encounter and infect non-immune human or animal populations, the resultant disease is more severe. The best fictional example of this is when the Martians succumbed to our cold viruses and common colonizing bacteria. A real life example is syphilis. When the syphilis bacteria appeared in Europe in the late 15^th century, it was a severe, often lethal infection termed “the Great Pox.” It ravaged Europe and an international blame game ensued. It was called “the French disease” by the English and Germans, “the Spanish disease” by the French, “the Polish disease” by the Russians, “the Turkish disease” by the Persians, and so on. Insensitive societal blame lives on with references to COVID as “the Chinese virus” or Kung flu. Early reference to AIDS as “the Haitian disease” is another example. Undoubtedly, however, some people in other countries to this day refer to AIDS as “the American disease” even though it clearly originated in Africa as detailed by Quammen in his book “Spillover.” 

Louis Pasteur is quoted as having said, “the microbes will always have the last word”. COVID-19 caught us with our guard down but I’m confident we will overcome it. This is bad, but it is not “the big one” on the pandemic Richter scale. The hope is that we will be readier for the next pandemic when it does occur.