My Comments: I found this to be a rational, entertaining and objective analysis of circumstances in which we find ourselves. It’s ubiquitous, and it’s potential for doing harm to me and my family is not far from my conscious thoughts seven days a week.
I’m not sharing in an attempt to assign blame for what we’re experiencing. If there’s any to be found, it will surface over time and future guardians of the galaxy and historians will make a judgement.
I like finding clarification for complex issues. Some of it might help me better respond to future threats. I’m sharing it so those of you with similar concerns might enjoy some additional clarity.
by David Quammen \ MAY 04 2020 \ https://tinyurl.com/yddo3mps
In 2006, the idea that an unknown virus might spill out of some wild animal into humans, achieving person-to-person transmission and causing a global pandemic, seemed a distant prospect to most people. As an engaging science-fiction scare, it ranked somewhere beneath “Alien: Resurrection.” But Ali S. Khan, of the National Center for Zoonotic, Vector-Borne, and Enteric Diseases, was tasked with dreaming that nightmare by daylight.
NCZVED (pronounced “N. C. Zved,” according to Khan), part of the Centers for Disease Control and Prevention, resided in an unobtrusive gray brick building, behind locked gates and locked doors in the C.D.C.’s compound on Clifton Road, six miles northeast of downtown Atlanta. During a two-day visit that year, I worked my way along the NCZVED corridors, interviewing scientists who knew all about Ebola viruses (yes, there are more than one) and their lethal cousin Marburg; about West Nile virus in the Bronx and Sin Nombre virus in Arizona; about simian foamy virus in Bali, which is carried by temple monkeys that crawl over tourists, and monkeypox, which reached Illinois in giant Gambian rats sold as pets; about Junin virus in Argentina and Machupo virus in Bolivia; about Lassa virus in West Africa, Nipah virus in Malaysia, Hendra virus in Australia, and rabies everywhere.
All these viruses are zoonotic, meaning that they can pass from animals to people. Most of them, once in a human body, cause mayhem. Some of them also transmit well among people, bursting into local outbreaks that may kill hundreds. They are new to science and to human immune systems; they emerge unpredictably and are difficult to treat; and they can be especially dangerous, as reflected in the name of the branch within NCZVED that studied them—Special Pathogens. For these reasons, some scientists and public-health experts, including Ali Khan, find the viruses an irresistible challenge. “It’s because they keep you on your toes,” he told me. On the second day of my visit, amid the intriguingly gruesome briefings, Khan took me out for sushi.
Khan is a medical doctor by training, an epidemiologist by career, and a man of candid, irreverent jocularity. He was wearing an epauletted uniform sweater; at the time, he was also an officer in the United States Public Health Service, which is organized into ranks, like those in the U.S. Navy. “You’ve heard all the talk from our people,” he said. “Which of these diseases is your favorite?”
My favorite? Ebola is pretty damn interesting, I told him.
“Aaah,” Khan said dismissively. “I like Ebola as much as the next person.” He had done crucial epidemiological work during the 1995 Ebola outbreak in Kikwit, in what was then Zaire, organizing control measures, investigating transmission, tracing the outbreak back to its Patient Zero, risking his life to help end a juggernaut of misery and death. He continued, “But, for my money, SARS was the one.”
SARS? I knew of it only as a bad viral disease that, in 2003, came out of southern China and killed people in Toronto, Singapore, and a few other cities. The acronym stands for “severe acute respiratory syndrome.” It’s an ugly illness that can lead to lethal pneumonia. A little more than eight thousand people were infected, of whom about ten per cent died, and then the outbreak ended. “Why SARS?” I asked.
“Because it was so contagious, and so lethal,” he said. “And we were very lucky to stop it.” SARS was the bullet that went whistling past humanity’s ear. This was on our lunch break, I had stopped taking notes, and it was fourteen years ago, so I can’t swear that Khan mentioned the other thing that is most relevant about SARS: It was caused by a novel coronavirus.
Ali Khan is now the dean of the College of Public Health at the University of Nebraska Medical Center, in Omaha. He seems an unlikely Omahan: born and raised in Brooklyn, by Pakistani immigrant parents, he went to Brooklyn College, followed by SUNY Downstate (in Brooklyn) for medical school. “And then I did this crazy thing of leaving Brooklyn”—crazy to his family, “because I have uncles and aunts who have never yet left Brooklyn to go to the city.” His father, Gulab Deen Khan, was a self-made man of the epic sort: as a teen-age peasant farmer, he trekked from Kashmir to Bombay, lied about his age, and got work on a ship, greasing engines. His friends called him Dini, as a diminutive, because he was small. After moving to the U.S., Dini Khan stoked coal in boilers to heat apartment buildings in Brooklyn until he had saved enough to buy an apartment building himself. He made money—what seemed a fortune. Before he lost it, in another speculation, Dini Khan decided that his young son, Ali, should learn about his family’s culture, religion, and language.
He sent Ali back to Pakistan for middle and high school. By parental miscalculation, he chose a classic British boarding school in Lahore, a better place to learn cricket than Urdu or Islam. Ali Khan, now fifty-six years old, told me this story, punctuated with laughs, when I reached him recently by Skype. His dark hair and beard had grayed a bit, but he still looked fit and sounded jovial. He spoke of Omaha like a pitchman for the Chamber of Commerce: great city, safe, unpretentious ethos, full of billionaires, such as Warren Buffett, who live in their old family homes, drive their little Buicks, and write million-dollar checks to the community.
“I love being a dean,” he said. “It’s so much fun.” He went to Omaha in 2014, leaving the directorship of the C.D.C.’s Office of Public Health Preparedness and Response, which included overseeing the Strategic National Stockpile of emergency medical supplies, supervising eight hundred employees, helping assemble a national biodefense strategy against pandemic threats, and much else. “The end of my career at C.D.C., I managed a $1.5-billion budget, so it was people and money.” He had travelled the world on outbreak responses, from Wyoming to Bangladesh. During a mission to southern Chile, investigating a hantavirus outbreak, he visited remote villages, sometimes on horseback, trapping rodents to determine which species carried the virus. “We learned quickly that there were a lot of rodents,” he said. After he worked on Rift Valley fever in Saudi Arabia, in 2001, the Saudi Minister of Health gave him a Lucite replica of a beheading sword as a token of gratitude. At one dicey moment in central Zaire, during an outbreak of monkeypox, he and his team got word that two sets of combatants in the raging civil war—Laurent Kabila’s guerrillas and the opposing forces of President Mobutu—were coming.
“They’ll likely take your vehicles and gear,” an American Embassy contact advised by satellite telephone. “But they probably won’t kill you.” Khan’s group packed fast and vamoosed on a small airplane, which rose straight into a thrashing thunderstorm. “The guy on my left was praying,” Khan recounted in a book, “The Next Pandemic,” full of colorful field adventures and serious warnings, published in 2016. “I looked over and saw that the French physician sitting next to me was writing a farewell note to his family. Which got me thinking.” His thought: This is a risky profession, and the work has to be worth a person’s life. For more than two decades at the C.D.C., it evidently was. In 1995, he did that hitch in Kikwit, Zaire, for Ebola. The following year, he went to the Sultanate of Oman to help with Crimean-Congo hemorrhagic fever. Uganda, in 2001, for Ebola again. SARS, in Singapore, in 2003. Chad was still struggling to eliminate polio in 2008, and Khan went there.
But, toward the end of his tenure with the C.D.C., as a high-level bureaucrat, he was responsible for orchestrating, not investigating; science was a small slice of the job. “Now it’s almost all science,” he said. Virology, epidemiology, ecology, and other aspects of disease science provide the substance of his mission, “educating the next generation of public-health practitioners.”
The eclectic décor of his current office includes electron micrographs of various pathogens hung like portraits in a rogues’ gallery, two sculptures of mosquitoes as big as crows, a “Star Wars” clock, a “Big Hero 6” toy robot, cards sent from children all over the world, mementos and gifts from his travels—a Congolese incense burner, the Saudi beheading sword—and a whiteboard on which he records what he calls “my metrics.” His precious metrics: measures of progress toward academic goals for his school, scientific goals, philanthropic goals to support the work. “I’m evidence-based and evidence-driven,” he said.
I asked Khan about COVID-19. What went so disastrously wrong? Where was the public-health preparedness that he had overseen at the C.D.C.? Why were most countries—and especially the U.S.—so unready? Was it a lack of scientific information, or a lack of money?
“This is about lack of imagination,” he said.
There were warnings. One of them was Khan’s favorite disease, SARS. In late 2002, an “atypical pneumonia” of unknown origin began spreading in and near the city of Guangzhou, in southern China—one of the largest urban agglomerations on the planet. In January, 2003, in the body of a portly seafood merchant suffering a respiratory crisis, the virus reached a Guangzhou hospital. In that hospital, and then at a respiratory facility to which he was transferred, the man coughed, gasped, spewed, and sputtered during his intubation, infecting dozens of health-care workers. He became known among Guangzhou medical staff as the Poison King. In retrospect, disease scientists have applied a different label, calling him a super-spreader.
One infected physician, a nephrologist at the hospital, experienced flu-like symptoms but then, feeling better, took a three-hour bus ride to Hong Kong for his nephew’s wedding. Staying in Room 911 of the Metropole Hotel, the doctor became sick again, spreading the disease along the ninth-floor corridor. In the days that followed, other guests on the ninth floor flew home to Singapore and Toronto, taking the disease with them. Several weeks later, the World Health Organization called it SARS. (The Metropole, having become notorious, was later renamed.) By March 15th, the W.H.O. was reporting a hundred and fifty new SARS cases worldwide.
Two mysteries loomed, one urgent and one haunting: What was the cause—a new virus, and if so what kind?—and from what sort of animal had it come? The first mystery was soon solved by a team led by Malik Peiris, a Sri Lankan doctor who got a degree in microbiology at Oxford before going to the University of Hong Kong. Peiris specialized in influenza, and he suspected that H5N1, a flu virus that is troublesome in birds and often lethal in people but not infectious person-to-person, might have evolved into a form transmissible among humans. His team managed to isolate a new virus from two patients. It was a coronavirus, not a flu bug—that is, it was from a different virus family, with different familial traits. But the mere presence of this new virus in two SARS patients did not mean that it was the cause of the disease. Then Peiris’s team showed with antibody testing that it might indeed be the SARS agent, and further work proved that they were right. Although earlier tradition tended toward naming new viruses by geographical association—Ebola was a river, Marburg a city in Germany, Nipah a Malaysian village, Hendra an Australian suburb—greater sensitivity about stigmatization prevailed. The pathogen became known as SARS-CoV. Recently, the name has been revised to SARS-CoV-1, so that the agent of COVID-19 can be called not Wuhan virus but SARS-CoV-2.
SARS reached Toronto on February 23, 2003, carried by a seventy-eight-year-old woman, who, with her husband, had spent several nights of a two-week trip to Hong Kong on the ninth floor of the Metropole Hotel. The woman sickened, then died at home on March 5th, attended by family, including one of her sons, who soon showed symptoms himself. After a week of breathing difficulties, he went to an emergency room and there, without isolation, was given medication through a nebulizer, which turns liquid into mist, pushing it down a patient’s throat. “It helps open up your airways,” Khan told me—a useful and safe tool to prevent, say, an asthma attack. But, with a highly infectious virus, unwise. “When you breathe that back out, essentially you’re taking all the virus in your lungs and you’re breathing it back out into the air—in the E.R. where you’re being treated.” Two other patients in the E.R. were infected, one of whom soon went to a coronary-care unit with a heart attack. There he eventually infected eight nurses, one doctor, three other patients, two clerks, his own wife, and two technicians, among others. You could call him a super-spreader. One E.R. visit led to a hundred and twenty-eight cases among people associated with the hospital. Seventeen of them died.
In Singapore, the first SARS case was a young woman who had also stayed at the Metropole, and had, on March 1st, sought help for fever, cough, and pneumonia at Tan Tock Seng Hospital, one of Singapore’s largest facilities. She had visitors, and, when several of them returned as patients, doctors suspected something contagious. Then four nurses from the young woman’s ward called in sick on one day, an abnormality noticed by Brenda Ang, a physician who was in charge of infection control at the hospital. “That was the defining moment for me,” Ang, a tiny, forthright woman, said, when I visited her at the hospital. “Everything was accelerating.” It was Thursday, March 12, 2003, the day that the W.H.O. issued a global alert about this “atypical pneumonia.”
At about that time, Ali Khan arrived in Singapore, serving as a W.H.O. consultant (seconded from the C.D.C.) to help organize an investigation and a response. He met daily with Suok-Kai Chew, the chief epidemiologist at the Ministry of Health, and along with others they developed strategy and tactics, getting governmental coöperation through a SARS task force. The public-health strategy was isolation and quarantine. “Before this outbreak, quarantine and isolation were not often evoked for infectious-disease outbreaks,” Khan told me—at least, not in the recent past. During the medieval plagues in Europe, infected unfortunates were sometimes sent outside city walls, to die or recover; the Mediterranean seaport Ragusa (now Dubrovnik) established a trentino, a thirty-day quarantine for travellers arriving from plague zones. In late-nineteenth- and early-twentieth-century America, during smallpox outbreaks, victims showing pox (especially if they were poor people or people of color) could be confined in quarantine camps, surrounded by high fences of barbed wire, or in nightmarish “pesthouses”—not so much to be treated but for the safety of the general populace. “That was a concept that had sort of gone out of vogue,” Khan told me dryly. He and Chew and their colleagues revived it in a more humane version.
Tan Tock Seng started treating only SARS patients, with other sick people diverted to Singapore General. Every suspected or probable case of SARS went into isolation at T.T.S., and the definition of “suspected or probable” was expanded beyond W.H.O. guidelines to include anyone with a fever or respiratory trouble. All health-care workers suited up with personal protective equipment, including N95 masks, and they were required to check themselves for fever or other symptoms three times a day. Medical staff were also restricted to one institution, so they couldn’t carry the virus between hospitals. During risky procedures, such as intubating a patient, they wore respirator helmets that pumped in purified air.
Firm measures were also taken to limit the disease’s spread in the community. As of March 27th, schools closed, and the bodies of those who died of SARS were cremated within twenty-four hours. Investigators traced close contacts of each new SARS patient, also within twenty-four hours, and those contacts were consigned to mandatory self-quarantine. “O.K., you are staying home. There will be a camera we’re setting up in your house, and there’s a phone,” Khan said, recounting the instructions. “We will call you randomly, and you’re expected to turn on the camera and be there.” Already, more than eight hundred people were quarantined. Flout the home quarantine, and you’d be tagged with an electronic tracer, such as an ankle bracelet.
Mandatory quarantine brought logistical challenges, Khan told me: “ ‘The moment you hold ’em, you own ’em,’ is what we say.” You’ve got to feed these people, see to their health care, make sure they are housed and clothed. “Who takes care of them? Who pays for them?” If you’re the government ministry enforcing self-quarantine, you do.
By April 24th, twenty-two people had died, at which point penalties for quarantine-breakers stiffened: bigger fines, the possibility of jail. Taxi-drivers had their temperature checked daily. Passengers departing and arriving at Changi Airport were also screened, as well as people travelling in buses and private automobiles. On May 20th, eleven people were fined three hundred dollars each for spitting. These measures worked. On July 13, 2003, the last SARS patient walked out of Tan Tock Seng and it was over. Some people loosely say that SARS “burned out,” having killed only seven hundred and seventy-four people worldwide. It didn’t burn out. As Ali Khan told me, it was stopped.
“What are you most concerned about now?” I asked Brenda Ang, at Tan Tock Seng, six years later.
She laughed in frustration. “Complacency,” she said. “And apathy.” Mundane but crucial infection-control measures—the assiduous hand washing and wiping of doorknobs with alcohol—can lapse after a crisis. “People become complacent. They think there is no new bugs around.” And larger lessons, beyond the outbreak locale, beyond Singapore? “There’s no point just protecting your own turf,” she said. “Infectious diseases are so globalized.”