Coronavirus: ‘you may have heard of a game called Plague Inc’

Ashley Arabasadi is senior external affairs manager and former health security policy adviser at Management Sciences for Health, an American-based nonprofit global health organisation. She was also campaign manager for its No More Epidemics campaign. She is chair emeritus of The Global Health Security Agenda Consortium, and previously worked for International Medical Corps, leading the organisation's efforts on the Global Health Security Agenda after managing large disaster response programs in Asia.

Q: It's a turbulent time due to Covid-19. What is it like for someone working in your field?

A: As a health security person, you are always thinking about preventing outbreaks, epidemics and the worst case scenario – a pandemic. And then when they happen, it is almost like you are watching in slow motion.

In the US where I am based, we held a pandemic simulation on Capitol Hill in Washington DC last year with a few key staffers who theoretically would be involved in making some of these key decisions to familiarise them with the issues that they would be asked to consider. During that simulation, each of them played a different role of different agencies reporting to the White House. Seeing that simulation actually play out in real life has been terrifying, but really interesting in terms of the amount of preparedness we have, versus what we need in reality. It has been an eye-opening dichotomy.

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Q: Could you summarise how this epidemic happened, and how we got to where we are now?

A: China detected a novel type of coronavirus coming out of Wuhan in late 2019. As the cases began to spread, and spread faster than anyone in China had anticipated, the government took drastic measures, like travel restrictions and city-wide quarantines. At one point they had quarantined 46 million people, even restricting how often people could leave their homes for food. At the time, WHO [the World Health Organisation] got involved in working with Chinese authorities. WHO declared a public health emergency of international concern. That was done to help get public health experts to work with Chinese governments to help contain that spread. However as we know now, the virus has spread to almost every region on the globe.

Q: How would you characterise Covid-19?

A: A pandemic means that it has spread to a number of countries and continents, and this disease is now spreading among communities. It's impossible to do case tracing, meaning that many people will never know how they contracted it. It is also very contagious. Each person can infect about two people, which is more than for seasonal flu. But if you are not immune compromised or have an underlying health condition, you will likely recover at this point.

Approximately 80 per cent of people who are infected are able to recover from the illness and the symptoms without lasting effect. But we are learning more about this virus every day.

A complication is with the timing of this as it is flu season in a lot of countries. Hospitals have a certain number of quarantine beds, and have a certain number of respirators for people with breathing issues due to flu. The United States, for example, has only 2.8 hospital beds per 1,000 people , and it's the tail end of our flu season. Hospitals are already over-stretched, and then you combine that with this virus ... It makes things very difficult.

Q: You mentioned that, for most of the population, this is not a particularly serious illness in terms of the effects, and that about 80 percent can recover without major complications. So, in some ways does that make it more dangerous than, say, a disease with far more severe symptoms? That's to say, if a virus quickly kills the host, it doesn't spread as much ...

A: Some people may have heard of a game called Plague Inc. The player takes the role of the disease, and has to try and spread as far as possible. You can't be too fast because you will kill all the hosts, and you can't be too slow because people will come up with a cure. Where the danger lies with a virus like Covid-19 is that people who are asymptomatic or who have mild symptoms will go out and about and can potentially spread this to somebody who is more vulnerable.

By the time somebody has symptoms, that person has potentially already been infecting others. This time lag also means that it can be very hard to do contact tracing afterwards.

We have to think about others. It is not the case that I, as a middle-aged person, am not concerned about getting the virus. I know that I will likely recover, even if I might feel unwell for a few days. But I am worried what could happen if I come in contact with my elderly neighbour, as people over the age of 70 have a higher risk of dying from it.

So we have a big responsibility to adhere to public health guidelines. That includes getting tested, social distancing, and washing your hands. Doing all these things they tell you to do to help flatten that curve of the epidemic or pandemic.

Q: So what would you say to those claiming online and elsewhere that it is just a type of influenza?

A: Oh gosh, the epidemic of misinformation is incredible. I think WHO is calling it an infodemic. Covid-19 is not the flu. I mean, the symptoms could feel like a flu, but it is not a flu. And for certain members of our community, it is far worse.

Q: There are projections in Ireland and other countries that 60 to 80 per cent of the people could end up infected. Is that plausible?

A: I have seen some predictions that 90 per cent of populations will become infected, but it's very hard to tell. There are so many theories, and the situation continues to evolve. This novel strain of coronavirus is only a few months old. So we're still learning a lot about it. There are people who say that this could die out in the warmer months, and there are other scientists who say no, that this could be endemic, that it could continue on. Experts around the world are working tirelessly to determine how the trajectory of the disease is going to continue. Some countries have prior experience of viruses like this. In places such as South Korea, which dealt with SARS, they are better prepared to act quickly and appropriately because they have the muscle memory of going through something like this in the recent past.

Q: Which we don't, obviously ...

A: Right. What is very interesting to me as a global health professional is that we seeing this spread in places where you would not typically see disease outbreak spread so quickly. It is all over parts of Europe. Italy is one of the three countries that have the highest number of confirmed cases. You don't expect to see that in a place with such a strong central government and a functioning health system. However in South Korea, which has more experience in infectious disease outbreaks, they were able to test widely and institute measures to slow the spread.

Q: What would you like to see other countries, such as the US, Ireland, the UK, do? Are authorities taking this seriously enough?

A: I think that governments are now understanding the scale of the crisis and are taking measures to ensure the safety of all citizens. I think that broader measures including stay at home orders will be key in flattening the curve and even with those measures in place, that it is going to take weeks if not months.

Beyond this outbreak and to mitigate the impacts from future outbreaks, what is really needed is sustained investments in health systems strengthening and health security in the US, UK and globally. We know that investments in healthcare infrastructure can make countries more resilient and able to withstand disruptions, like those caused by infectious disease outbreaks.

Q: It's really striking how this has spread. Not long ago the vast majority of cases were in China – now it has gone to many countries around the globe ...

A: Yes. I don't know when we are going to start to see the virus slow down. If you look at Wuhan, now, there are fewer cases being reported inside its borders than are reported outside. That means that they are successful in containing the virus, in slowing it down, that the quarantine and the drastic measures that they have taken is starting to work. The United States is starting to step up lockdown as well. Entire states, such as California, with a population of 40 million, are on lockdown.

We are projecting that it is going to get a lot worse in our country. All leading experts have said this. I would imagine that other countries who aren’t taking extreme measures to contain or protect will see the same disease trends we saw in other hard-hit places. By that I mean it starts a little bit slow, there are delays in testing, and then it will really take off. You will see cases just going through the roof.

Q: I presume you are worried by what could happen?

A: I am concerned. I am mainly worried for my parents, for my husband's grandmother who is in her 90s, and for those who have compromised or suppressed immune systems.

My organisation has recommended working from home, just so that everyone isn’t in the office and in close quarters.

And a lot of companies are doing the same. Seattle, a major city on the West Coast, has closed all public schools. When you look at things like that, there are other knock-on effects too. With schools closed, the kids are at home, there are gaps in education, and there are other effects too. Like those on the federally-funded programmes that provide school lunches for some of the children. So, really, the ripple effects of this are what are really concerning.

I know this is going to have huge economic impacts on communities in our countries. And that is scary. In Washington, DC, our beautiful cherry blossom trees are blooming. People from many states and countries come to see them, go to our museums, visit bars and restaurants, and tour our monuments. Those areas are now largely closed to pedestrians.

South by Southwest, which brings in over 380 million dollars for the city of Austin, particularly for local businesses like restaurants, bars and clubs, has been cancelled as well.

So the loss of revenue is going to be very hard on small business owners, on independent entrepreneurs. That will happen as this virus hits Ireland or as it hits part of England or Italy… Italy has Milan, Rome, Venice, all of these cities that benefit from tourism. They are also going to see economic impacts for years to come.

Q: We are talking about a virus which is affecting almost every area of the globe. This year was supposed to be Olympic year, but it is now postponed until 2021 in Japan. What about something like the Tour de France, which similarly has competitors and spectators from a wide range of locations?

A: I have never attended the Tour de France but I have seen pictures of the fans gathering along the roadsides and waving. I would think that it, like so many other large gatherings, will be cancelled.

Q: Is it fair to say that a major sporting event with competitors and spectators from around the globe in one place is a dangerous situation?

A: I certainly would not attend. In the US, we have cancelled some of our biggest events, something that would have been unthinkable a month ago. The Boston Marathon has been postponed for the first time in its 122-year history. The National Basketball Association has cancelled its season. The National Hockey League, which does play international teams as well as domestically, has postponed its season. And Broadway has shuttered for a month … theatre goers tend to skew a little bit older, especially in Washington DC. So I think we are going to see a lot of others following suit in an effort to limit the spread.

Q: Do you see any similarities between this and the 1918 flu pandemic?

A: When you have something like this that is spreading, and spreading quickly, I think you can always draw some correlations. My colleague Jonathan Quick (the former chair of the Global Health Council and a long-term collaborator of the World Health Organisation) draws a lot of correlations between the 1918 flu pandemic and measures that happened then, including increases in global transportation and troop movement due to World War I.

Now versus then is obviously different – we know a lot more now, we have better trained doctors, we are able to act quicker. But with that previous pandemic, it was relatively mild when it hit the year before, and then re-emerged as a killer flu. That is worrying.

Q: Can you explain how that ended?

A: It didn't end very well. An estimated 50 to 100 million lives were lost. Public health officials then didn't take the drastic measures needed to help limit or stop the spread of the outbreak. Social gatherings, including one notable parade in Philadelphia were still held which caused a massive outbreak to spread in the city. Meanwhile, the city of St. Louis implemented individual quarantines and bans on public gatherings. According to our National Institutes of Health, St. Louis's mortality rate from the flu was only one-eighth of Philadelphia's.

Q: Looking at Covid 19, how do you think this particular epidemic will end?

A: Hopefully better than 1918. This month President Trump signed a bill allocating 8.3 billion dollars from US funds to help the domestic and global response. The WHO is receiving funding from the private sector, as well as from different governments. The US is putting that money towards frontline health workers, medical supplies, pharmaceuticals, and more. It's worth noting that a significant amount of that has been allocated towards the development of a vaccine.

There isn’t a cure right now, we don’t have a vaccine. I know a lot of companies are working on that, but even if we fast-track research and deployment it is still about a year and a half out. My hope right now is that even if the virus is widespread, that it remains not particularly deadly for the majority of the population.