Coronavirus footnote1 is the old movie that we’ve been watching over and over again since Richard Preston’s The Hot Zone (1994) introduced us to the exterminating demon, born in a mysterious bat cave in Central Africa, known as Ebola. It was the first in a succession of new diseases erupting in the ‘virgin field’ (that’s the proper term) of humanity’s inexperienced immune systems. Ebola was soon followed by avian influenza, which jumped to humans in 1997, and sars, which emerged at the end of 2002; both initially appeared in Guangdong, the world’s manufacturing hub. Hollywood, of course, lustfully embraced these outbreaks and produced a score of movies to titillate and scare us. (Steven Soderbergh’s Contagion, released in 2011, stands out for its accurate science and eerie anticipation of the current chaos.) In addition to these films, and the innumerable lurid novels, hundreds of serious books and thousands of scientific articles have responded to each outbreak, many emphasizing the appalling state of global preparedness to detect and respond to such novel diseases.
So Corona walks through the front door as a familiar monster. Sequencing its genome (very similar to its well-studied sister sars) was simple enough, yet the most vital bits of information are still missing. As researchers work night and day to characterize the virus, they are faced with three huge challenges. First, the continuing shortage of test kits, especially in the United States and Africa, has prevented accurate estimates of key parameters such as reproduction rate, size of infected population and number of benign infections. The result has been a chaos of numbers. Second, like annual influenzas, the virus is mutating as it courses through populations with different age compositions and health conditions. The variety that Americans are most likely to get is already slightly different from that of the original outbreak in Wuhan. Further mutation could be benign, or it could alter the current distribution of virulence which now spikes sharply after age 50. Either way, Trump’s ‘corona flu’ is at minimum a mortal danger to the quarter of Americans who are elderly, have weak immune systems or suffer from chronic-respiratory problems.
Third, even if the virus remains stable and little mutated, its impact on younger age cohorts could differ radically in poor countries and amongst high-poverty groups. Consider the global experience of the Spanish Flu in 1918–19, which is estimated to have killed 1 to 2 per cent of humanity. In the us and Western Europe, the original h1n1 in 1918 was most deadly to young adults. This has usually been linked to their relatively strong immune systems, which overreacted to the infection by attacking lung cells, leading to viral pneumonia and septic shock. More recently, however, some epidemiologists have theorized that older adults may have been protected by ‘immune memory’ from an earlier outbreak in the 1890s.
Spanish Flu found a favoured niche in army camps and battlefield trenches where it scythed down young soldiers by the tens of thousands. This became a major factor in the battle of empires. The collapse of the huge German spring offensive of 1918, and thus the outcome of the War, has been attributed to the fact that the Allies, in contrast to their enemy, could replenish their sick armies with newly arrived American troops. But the Spanish Flu in poorer countries had a different profile. It’s rarely appreciated that almost 60 per cent of global mortality, perhaps 20 million deaths, occurred in the Punjab, Bombay and other parts of western India, where grain exports to Britain and brutal requisitioning practices coincided with a major drought. Resultant food shortages drove millions of poor people to the edge of starvation. They became victims of a sinister synergy between the flu and malnutrition, which suppressed their immune response to infection and produced rampant bacterial, as well as viral, pneumonia. In a similar case in British-occupied Iran, several years of drought, cholera and food shortages, followed by a widespread malaria outbreak, preconditioned the death of an estimated fifth of the population.
This history—especially the unknown consequences of interactions with malnutrition and existing infections—should warn us that covid-19 might take a different and more deadly path in the dense, sickly slums of Africa and South Asia. With cases now appearing in Lagos, Kigali, Addis Ababa and Kinshasa, no one knows (and won’t know for a long time because of the absence of testing) how it may synergize with local health conditions and diseases. Some have claimed that because the urban population of Africa is the world’s youngest, with over-65s comprising only 3 per cent of the population—as opposed to 23 per cent in Italy—the pandemic will only have a mild impact. In light of the 1918 experience, this is a foolish extrapolation. As is the assumption that the pandemic, like seasonal flu, will recede with warmer weather.
More likely, as Science warned on 15 March, Africa is ‘a ticking time-bomb’.footnote2 In addition to malnourishment, the fuel for such a viral explosion is the huge number of people with crippled immune systems. hiv/aids has killed 36 million Africans over the past generation, and researchers estimate that there are currently 24 million cases, along with at least 3 million suffering from the ‘white plague’, tuberculosis. Some 350 million Africans are chronically malnourished, and the number of small children whose growth has been stunted by hunger has been increasing by millions since 2000. Social distancing in mega-slums like Kibera in Kenya or Khayelitsha in South Africa is an obvious impossibility, while more than half of Africans lack access to clean water and basic sanitation. Additionally, five of the six nations with the world’s worst healthcare are in Africa, including the most populous, Nigeria. Kenya, a country well-known for exporting nurses and doctors, has exactly 130 icu beds and 200 certified icu nurses to greet the arrival of covid-19.
A year from now we may look back in admiration at China’s success in containing the pandemic—and in horror at the us’s failure. (I’m making the heroic assumption that China’s declaration of rapidly declining transmission is more or less accurate.) The inability of us institutions to keep Pandora’s Box closed is hardly a surprise. Since 2000 we’ve repeatedly seen breakdowns in frontline healthcare. Both the 2009 and 2018 flu seasons, for instance, overwhelmed hospitals across the country, exposing the drastic shortage of hospital beds after years of profit-driven cutbacks of in-patient capacity. The crisis dates back to the corporate offensive that brought Reagan to power and converted leading Democrats into neoliberal mouthpieces. According to the American Hospital Association, the number of in-patient hospital beds declined by an extraordinary 39 per cent between 1981 and 1999. The aim of this reduction was to raise profits by increasing ‘census’ (the number of occupied beds). But management’s goal of 90 per cent occupancy meant that hospitals no longer had capacity to absorb patient influx during epidemics and medical emergencies.