Journal of the plague year 1

It seems hard to believe now, but one month ago was the date that the National Basketball Association suspended its season after its first player tested positive for the novel coronavirus. That was the same date that Tom Hanks and his wife, Rita Wilson, announced that they were self-isolating with the viral infection. It has been exactly one month since the lives of many in the U.K., North America, and elsewhere were changed, as drastically as they’ve changed in generations.

We will have occasion, eventually, to wonder why it didn’t seem real until a month ago, even as it ravaged first China and then Italy. Perhaps it is human nature to expect things to go on normally, until they don’t. Certainly this situation is unprecedented, and more global in its scale than anything the world has gone through previously, at least since the Second World War. 

The war comparison is apt, but perhaps not for the reasons politicians think. Americans especially have grown accustomed to “wars” that are undeclared, that drag on endlessly, yet only ever involve a small number of people (at least on the U.S. side). They are not wars in the sense that World War II was a war, where real sacrifice was demanded on the home front. This was even truer in Europe, where civilians as well as military personnel were in danger of death. Now, for the first time in most living people’s memory, we are being called upon to face an unexpected and largely unknown danger. The timing and the outcome are uncertain. 

Many of us are facing only a very low level of danger in this war, but a large number of people are taking greater risks. We are not accustomed to thinking of war this way—not against some other nation or group whose fault it is, but against a disease. A disease that clearly does not discriminate. The virus can lay low Tom Hanks and the British prime minister. It does not care if its host is Spanish or Chinese.

We are also not accustomed to thinking of disease this way. Since World War II, in fact, we have had antibiotics, and they have been the “miracle drugs” despite our best efforts to overuse and thereby dilute them. Vaccinations, despite the freedom of people in democratic societies to forego them, have largely removed child mortality from our privileged societies. People of my generation and younger were never even vaccinated against smallpox; it was considered eradicated. Most research and investment goes into the diseases of rich societies: heart disease, cancer, type 2 diabetes mellitus. In wealthy Western nations, millions of adults take a class of drugs (statins) not because they have heart disease, but for a risk factor. We don’t even need a disease for a drug, and yet now, here is a new disease, for which we have no drugs. Nothing like this has arrived since HIV, which was transmitted in different ways and to different subsets of people.

We did not expect a communicable disease, against which the human body has no defense, to come against us and spread death from another person’s cough. That happened in other centuries—and happens, of course, in other societies. Though there were clues. The outbreak of severe acute respiratory syndrome (SARS) in Asia in 2003 spread to Toronto, where I was living at the time. For a while, we got used to seeing people wearing masks, and the cancellation of events, and visitors not coming to Toronto from other places. I got a new doctor during that time and it was months before I saw her face.

SARS went away and, importantly, has not returned (in the way that seasonal flu does). In part, that’s because it was well contained by public health measures, but it probably couldn’t have been were it not for particular characteristics. Unlike the novel coronavirus (whose official name is SARS-CoV-2), the first SARS seems not to have become communicable until a person was already showing symptoms. That made it much easier to identify and isolate who was sick than is the case with COVID-19.

In an interview in the spring of 2019, Dr. Anthony Fauci, the director of the U.S. National Institute of Allergy and Infectious Diseases, spoke with FiveThirtyEight’s Anna Rothschild. He made some comments then that did not make it into the article she was writing at the time, but now seem very prescient. When asked what kept him up at night, Fauci said: 

the thing I’m most concerned about as an infectious disease physician and as a public health person is the emergence of a new virus that the body doesn’t have any background experience with, that is very transmissible, highly transmissible from person to person, and has a high degree of morbidity and mortality.

Now what I’ve essentially done is paint the picture of a pandemic influenza. Now it doesn’t have to be influenza. It could be something like SARS. SARS was really quite scary. Thankfully, it kind of burned itself out by good public health measures. But the thing that worries most of us in the field of public health is a respiratory illness that can spread even before someone is so sick that you want to keep them in bed. And that’s really the difference.

We will have occasion, eventually, to wonder a lot about preparation and warning. The obvious comparison from my lifetime is September 11, and yet that really isn’t much of a comparison. More people are dying every day from COVID-19 than were killed on September 11. Unlike then, most if not all countries in the world are affected. How America responded to September 11, how it became a different place from the country I grew up in, is a better comparison than the deaths. How has our world already changed as a result of the COVID-19 outbreak, and which of those changes will outlast the pandemic? Could some of them even be positive? 

As I journal through this plague year, I am really resisting making the kind of judgments that can only be made by history. There are a lot of things we will have occasion, eventually, to pass judgment on. And it is tempting to foresee lessons in this that are biased towards one’s own predispositions. For example, to me, having lived with good public health care systems for twenty years, the U.S. for-profit hospital system—that has parts of America begging for health care workers while those in other parts are laid off*—seems crazy. Life-threatening. But that doesn't mean I know how, precisely, the U.S. ought to go about insuring everyone. COVID-19 doesn’t answer questions; it only raises them. 

What I think, cautiously, I can do is note the things that seem to be working, and some things that don’t, and ask the question, which might we incorporate into a future (please God) beyond the pandemic? There are relatively few people who are not reflecting at least a little bit, in this forced pause, on what is truly important. There is plenty of bad news to make us anxious, and finger-pointing if we want to get really worked up, but what can we learn in this time?

One thing that I am, humbly, learning is that I read and work on science papers all day, yet I didn’t have a very good idea of how science actually works. I read about the new virus and the damage it was doing in other countries in December, January, February, yet somehow, I wasn’t fully expecting the dramatic extent of what we are being asked to do in the U.K. until the day we were asked to do it. This is one reason I’m hesitant to declare that this or that person or agency should have known or done better months earlier. Science writer Maggie Koerth described this very well: Most of us learned, in school science classes, that science works by experiment, and then you have a fact, and you go memorize that fact and now we know something. When science is actually happening, though, it is not very clear at all. The novel coronavirus is something scientists just don’t know much about yet, although their efforts to tackle it are unprecedented, both in scale and speed (pretty much all other research having ground to a halt in the meantime). 

The Imperial College modeling I wrote about previously, for instance, has had enormous impact and yet, like many other studies being published so rapidly, was not peer reviewed. Peer review is normally an essential part of scientific research, to keep unprovable and unreplicable ideas from spreading in the academic realm and beyond. Like other safeguards, it’s not foolproof, but we should keep in mind that the models we are seeing (from Imperial or elsewhere) are still just based on assumptions. They may turn out, in retrospect, not to have been very accurate at all. The best we can hope is that we end up with far less death and destruction from this disease than the models predicted—but that won’t necessarily tell us that the models were wrong, just that we did a good job reacting to them.

I actually find the science kind of inspiring, because while politicians and others are tempted to blame other nations or pull up the drawbridge, research, especially on an urgent matter like this disease, is not about national rivalry. Colleagues in many countries share resources and are exchanging information about the virus as fast as they can, knowing that lives are at stake. As The New York Times recently reported, the closest comparison may be the very different plague that I remember from my own youth—AIDS, which ravaged Western communities in the 1980s and early ’90s. But today’s technology provides options, and speed, that researchers during the AIDS crisis did not have. (Thanks to Anthony Fauci and many others, HIV, which we first knew as a 100% fatal infection, has become a chronic disease, that it is possible--for those with resources--to live with.)

A lot of people are probably seeing more exponential graphs and grappling with data more than ever in their lives before. What we find most unnerving, besides the worry that we or someone we know may get sick, is the uncertainty. We are really not used to this. We expect the basketball season, Wimbledon, the Olympic and Paralympic Games to happen on time. We expect to go to work and for places to be open and to be able to fly to see someone in person, if we have the money. (Almost all the things we suddenly miss are things we could only ever do with money, and if this didn't occur to us before, I hope we are aware of it now.)

We all know that unexpected things can happen in life, to individuals. But most of us have no context to prepare us for something that affects everybody, the entire earth. 

And the uncertainty, more than COVID-19, is killing us. Will these lockdown measures work? We hope so, experts think they see signs of hope, but we don’t know in detail. When and how will they end? No one can tell us. Should I wear a mask? The Centers for Disease Control and Prevention say yes, the World Health Organization says no, and each has plausible reasons. Would it be better if the children went back to school? Maybe yes, maybe no. When? No one knows.

For the past three Thursday evenings, people across the U.K. have opened their doors and windows at 8:00 and clapped, banged pots and pans, and generally applauded carers and National Health Service workers doing such a heroic job. For people in other countries, it's hard to explain what the N.H.S. means to Britain. Long before this present crisis, it was hands down the most popular institution in the country. At the opening ceremony of the London 2012 Olympics, the featured sketch was people dressed as doctors and nurses, dancing around a hospital set. The “Brexit” campaign, which so divided people, was largely fought about how to get more money to the N.H.S.--something I've never heard anyone oppose.

But Britain’s response to the pandemic has been far from flawless and that’s not my point here. What happens each Thursday is that we look across and up and down our road and see our neighbors clapping, just as we are. They are all home, of course. We wave to them, sometimes chat (from a safe distance), and see that they are all right. Our neighbors on one side have a backyard separated from ours by a low fence, and the weather’s been nice, so we have regularly chatted with them. But on the other side, our neighbor Amy is someone we ordinarily don’t see for months at a time. We like Amy; she’s lived here much longer than I have. But in normal times, she’s out at work late, and has a busy social life. Other than at Christmas or the random bumping into her in town, I could go a year without talking to her. 

Not now. Now, I look forward every week to seeing Amy, and the guys across the street, and others who I always kind of know are there for us, but we don’t interact with. Now, everyone is knocking themselves out on a WhatsApp group and can’t do enough for each other. We can’t meet our friends in town or our family across the ocean, so we meet our neighbors. On the street, over the backyard fence, and every Thursday at 8:00 P.M.

In another part of the world, war-torn Yemen, a ceasefire has been announced. COVID-19 has arrived there too, and the Saudis and Iranians and their proxies, having just about destroyed the country, have been persuaded to give peace a chance, so there is at least some hope of enough stability to address this disease. 

The pandemic has brought Yemen and the neighborhoods of well-off countries a little closer together than they were before. It isn’t a rich-country disease, for which expensive drugs are developed and U.S. hospital systems are tailored. It isn’t a poor-country disease, like malaria, which ravages whole communities. It affects poor people disproportionately, as almost all problems do, but that’s as true of the worse-off in New York or New Orleans as it is in the Near East.

Roger Cohen wrote recently, “The world that emerges from this cannot resemble the old. If this plague that cares not a whit for the class or status of its victims cannot teach solidarity over individualistic excess, nothing will. If this continent-hopping pathogen cannot demonstrate the precarious interconnectedness of the planet, nothing will. Unlike 9/11, the assault is universal.”

A few days before non-essential businesses were closed in the U.K., I spoke with Trudy, a woman I’d met in a Lent group at church. Everybody, especially those aged over 70, sensed that “lockdown” was coming, but we still didn’t fully know what that was going to look like. I went to my hairdresser’s, which was empty, not knowing when I might get a haircut again. I bought a takeaway coffee from a shop that had already removed all its customer seating. Finally, I bought a Big Issue, sold in aid of homeless people, from our local vendor. The grocery store outside of which she typically plied her trade had given her a chair to sit on, as well as latex gloves. I had a chat with her and she smiled wide enough to show three gold teeth. I felt like I’d done my bit for local businesses.

The next day, the Big Issue took all its issues off the street. To protect its vendors, many of whom are homeless themselves; but where did they go? Will ours be back? 

I don’t know this woman’s story or if she is, herself, homeless. But I know that she is my neighbor, every bit as much as the hairdresser or the people who live on our road. 

There is a lot more to learn. I hope one of the things we remember is that a “good neighborhood” is not defined by real estate values, or who lives there, but by heart values and whether we take care of the people who are there. 

* The New York Times: “Amid pandemic, health care workers lose their jobs,” by Ellen Gabler, Zach Montague and Grace Ashford