Everything We Know about The Pandemic is Wrong – Or…
…Let’s Just Blame The Pathogen
Until quite recently, I thought this was a pattern limited to the travails of humans contesting with other humans. I have changed my mind.
I shared my perspective on the COVID19 pandemic early, and often, from a platform of general expertise in preventive medicine and public health. I was well aware that others had expertise more focused on pandemic response and virology, and I sought such counsel to inform my own. I was privileged to exchange reflections with world leading authorities.
One theme that emerged from such exchanges was that pandemics are intrinsically enigmatic. Just when you think they are winding down, they rebound. A receding wave may be followed by calm, or by a rougher wave, or a whole sequence of those. Seasonal variation in viral transmission may make sense, or defy it. As a result of all this, some of the most seasoned of pandemic response experts are the humblest. Their experience has been: the more they learn, the less they know. Pandemics are inscrutable.
I had no cause to doubt that conclusion then, never having lived the daily tumult of full-scale pandemic and global response. But now that what was once a dusty lesson in the archives of public health has been up close and personal for a year and a half, I believe I’ve had a revelation. What humans do in conflict with other humans, we do when in conflict with Nature, too.
There is nothing inscrutable or unpredictable about pandemics. Those perturbations all emanate from human dysfunction. But when the conflict has run its course, and humans remain to tell the story- we tell it in our own favor. We revise history, and blame the vexing vicissitudes of a bungled pandemic on…the pathogen.
I don’t buy that anymore.
The pathogens that are the agents of pandemics- the SARS-CoV-2 virus in the current case- have the simplest of mandates, a single imperative: spread. They have no intentions, no ambition, no creativity. They just replicate, and spread, opportunistically.
The outcome of that single, mindless objective is just as described by Richard Dawkins in his seminal work, The Selfish Gene. Better replicators displace lesser replicators. A virus that spreads better supplants other microbes populating that same ecological niche (human bodies in the case of pandemics), including alternative versions of itself.
The mutations that lead to viral strain divergence are a simple numbers game. Random mutations occur at some modest frequency in all cell lines. Most mutations are neutral or disadvantageous, and here again we can turn to Dawkins for a vivid explanation. If you turn the dial of a microscope with a field already in good focus, the focus is far more likely to worsen than improve. A good focus is hard to achieve, and only some very particular adjustment could take it from good to “better.” Every other alteration takes it from good, to worse.
Adaptation is the same. Organisms here, now, are adapted to the here and now. A mutation is that turn of the microscope dial. Only the rarest of those improves adaptation.
The salience of the numbers game every pathogen plays ensues. If a billion people are infected with SARS-CoV-2 (more than that surely have been), and if each of us infected harbors a viral load of a billion viral particles (virions; that, too, is a conservative figure) – that’s a quintillion virions. Such a number rarely enters the vernacular; it’s just too big. It’s a billion billions.
So, imagine that mutations occur once in each 1,000,000 viral replications (another conservative estimate). And imagine further that only one in 10,000 mutations is in any way advantageous to the virus. That translates to one advantageous mutation out of every 10 billion virions. But as noted, if there are a quintillion virions circulating, then as stunningly rare as favorable mutation is, it will occur 100 million times.
That’s a snapshot of the pathogen’s numerical advantage in its arms race with human immunity; the time series view makes matters more ominous still. Every generation of virions is a whole new opportunity for 100 million new, favorable mutations (my numbers are illustrative only). If a virion lives for some number of days, that is the length of a viral “generation.”
Pandemic duration, in other words, is not our friend. The total number of us infected, multiplied by the virion total in each of us, multiplied by the time span of the pandemic, is the staggering numerical sum creating opportunity for the virus to speciate, and keep spreading.
In the current pandemic, the virus has behaved just as such constraints would anticipate. In accounting for pandemic vagaries, we would, if honest, look to ourselves. We are the unpredictability.
Or, perhaps we are quite predictable. We are fractious and contentious; we are quick to judge and slow to trust. While the pathogen has only one objective, we have many, often in conflict with each other, and prone to change with fashion and fad. Our very ability to function as a unified team in response to a common, global threat – be it viral pandemic or climate calamity – is unproved, and very much in doubt.
Our most reasonable objective, for this and every pandemic, would be: minimize total harm. In such a simple reckoning, threats to lives are of greater weight than threats to livelihoods, but both count. Minimizing total harm is, or should be, to humans what “spread” is to the pathogen. But that was never the case.
We had no clear, guiding objective- not even for limited population groups, let alone the full mass of humanity. We locked down variably, indiscriminately, and generally too slowly- so that we locked down with the virus, rather than away from it. Because some populations locked down and others did not, there was always a vulnerable population awaiting further viral spread. When we did lock down, it was never with a clearly articulated timeline that would traverse the survival capacity of the virions locked down with us. We never had any clarity from any authority on what would constitute the “all clear,” how long it would take to get there, and what the indicators would be. All of this was possible. So too, in principle at least, was a globally coordinated lock down that ended the pandemic in weeks.
We liberated ourselves as haphazardly, and heterogeneously as we locked down, so once again- we guaranteed that viral circulation would never get to nil, and that there would always be a new population of vulnerables for the circulating virus to infect.
And when it seemed we might rely on the remarkable alacrity with which effective vaccines were achieved to save us from ourselves, we bungled that, too. From conspiracy theories, to questionable communication campaigns, to apathetic and inequitable distribution- the promise of vaccines has been squandered. They have made a great difference just the same, of course, but rather than providing a decisive turn-around affirming their monumental benefit, they have been mired in doubts about new strains with which their slow uptake has been concurrent.
We are unable, even, to agree on the simple expediency of masking. The virus, meanwhile, is perfectly immune to our ideological divisions, and unfailingly opportunistic in response.
Looking back, it seems clear a brisk, initial, globally coordinated lockdown could have robbed the virus of much of its opportunity to spread among us. An equally brisk, coordinated, phased return to the world based on risk differentials already on display might have given us a fast track to our lives back, minimized any harm done by residual virus circulating at low levels, and advanced us toward an early herd immunity. Meticulous protection of those most at risk of harm by focused resource allocations – vertical interdiction in my words, “focused protection” in the words of colleagues – until viral circulation was near enough zero to sound the all clear, vaccines were available, or both would have marshalled our most vulnerable through the crisis. We would have achieved our objective of total harm minimization, and denied the virus its own by minimizing access to the required real estate, our bodies.
Of course, it seems equally clear we were utterly incapable of any such degree of rational cooperation. So here we are, rewriting history even as it happens to us.
The virus was perfectly predictable, perfectly aligned with its single imperative. We were entirely unpredictable, except in our dysfunction, and never established a shared imperative let alone a shared means of achieving it.
Having lived this pandemic, I now doubt the historical narrative of every other. Like viral behavior, human nature is largely the same now as it ever was. Thus, the epiphany in observing this pandemic is what it says about all pandemics past. Our behavior now is our best guess at our behavior then, and the conclusion that ensues is: history books tell it all wrong.
We survived those past pandemics to be the archivists of them. As when humans overcome other humans, we blamed all misfortune on our opponent, the pathogen. We imbued mindless viruses and bacteria with inscrutability. We revised pandemic history to see our own fractious actions in a better light. Our revisionist history is so effective, even leading experts have been duped.
Why does this matter? Because those who don’t learn from the follies of history are destined to repeat them. In my 30 years as clinician, I routinely saw the “standard of care” excuse all manner of ineptitude and impropriety, for it was the mean of these. If the same is true of pandemic response, as I now suspect, the liabilities amplify to a global scale.
We have met the enemy, and it is, indeed, us. By denying that, and blaming the pathogen for the very vagaries we created, we likely consign ourselves to do it all again, just as badly, some day, too soon.
This article was first published on LinkedIn.
David L. Katz, MD, MPH is an Internist and board-certified specialist in Preventive Medicine and Public Health. He has co-authored five editions of a leading textbook on public health and epidemiology.
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