World War C

by Sanjay Gupta

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  To the soldiers of COVID-19, from all the doctors, scientists, and health care workers, to the survivors and victims young and old.

  To the children who will go bravely forward and carry these important lessons to the next generation.

  And to the collective breath of the world’s inhabitants… and the nature in which we coexist on this planet and persevere in our survival.

  Ingenuity, knowledge, and organization alter but cannot cancel humanity’s vulnerability to invasion by parasitic forms of life. Infectious disease which antedated the emergence of humankind will last as long as humanity itself, and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history.

  —William H. McNeill, Plagues and Peoples (1976)

  INTRODUCTION A “Pneumonia of Unknown Origin”

  The single biggest threat to man’s continued dominance on this planet is the virus.

  —Nobel Prize–winning biologist Joshua Lederberg (1958)

  New Year’s Eve 2019, Belize

  I was drinking wine with, of all people, Francis Ford Coppola while enjoying the beautiful coast of this Central American paradise hours before we’d ring in 2020. We were there as part of a climate change charity and had spent the day touring the surrounding coral reefs. It was a perfect day, and I remember feeling very much at peace. I distinctly recall Coppola asking me about a potential new virus that had been detected in the People’s Republic of China. Earlier that day we had both read reports buried in the back of the newspaper about “an outbreak of respiratory illness in the central city of Wuhan.”1 Some were already comparing it to the 2002–2003 severe acute respiratory syndrome (SARS) epidemic. The local health authority there had released a concerning epidemiological alert, stating that twenty-seven people had fallen ill with a strain of viral pneumonia, and seven were in serious condition. Fifty-nine more suspected cases with fever and dry cough were transferred to a designated hospital. While details from the Chinese government were vague, scientists and others were sounding louder and more detailed alarms. Hong Kong scientist Dr. Li-Meng Yan said a scientist at China’s Center(s) for Disease Control and Prevention, with firsthand knowledge of the cases, was very worried, confidentially telling her the illness might already be spreading human-to-human. It was hard to know what to believe.

  I remember everything about the moment sitting with the legendary filmmaker—the Godfather himself. I can still see both of his hands on the glass, filled with rich red wine. I can hear the clusters of family members romping on the beach and the kids giggling in the water. If I close my eyes, I can still smell the fragrant oceanfront air, rife with the tropics and the salt. Fact is, we were happy, and we were content. And, we had no idea how quickly that was all going to change.

  We had no way of predicting that within just a few months, millions of people around the world would become infected, overwhelming entire health care systems. Or that many people would die alone, isolated from their family in their last moments due to the remarkable contagiousness of the virus. I could not imagine the nightmares I would continue to have of those particular scenes more than a year later. My sleeping mind filled with patients lying prone on their bellies while brave nurses in full protective moon suits held screens in front of their faces so they could try for that final good-bye.

  Borders would close. Schools and colleges would shut their doors. Students would be abruptly sent home. I would spend more time with my wife and three daughters in one year than in the previous ten. Parents would wring their hands in the sudden messy juggle of overseeing their kids’ distance learning and holding on to their jobs—if they were lucky enough to keep them. Stadiums, theaters, museums, playhouses, and concert halls would become desolate as professional sports and arts would suddenly cease. Businesses halted, some forever, and global economies shuddered. Large gatherings would become a distant memory. Soap, wipes, hand sanitizer, and, inexplicably, toilet paper would vanish from store shelves.

  Personal protective equipment (PPE) would become as precious as gold, prompting some hospital heads to use their personal credit cards to buy whatever they could, no matter the price.2 People would hastily write their wills, sew masks from cloth, and draw down their savings accounts. Some would tap retirement accounts.

  Grandparents would soon become the loneliest members of our whole society.

  Peaceful protests juxtaposed with historic civil unrest would take to the streets as the pandemic yanked the veil off deeply rooted racial injustices. Political divides would widen. Individuals who’d never contemplated buying a gun now had second thoughts. Dangerous conspiracy theories would spread as fast as the virus itself, challenging the veracity of science and the integrity of scientists. Some of those scientists would receive credible death threats, and would be forced to live with around-the-clock protection.

  As dark as it was, there were also stunning bursts of light. The race for a cure would destroy academic silos. Business rivals in pharma would suddenly collaborate to develop vaccines. Public health experts, too often sidelined, would be in unprecedented high demand and quickly thrust to the front lines. Health workers everywhere would leave their families every day to be the only family of the dying, often risking their lives to do so. I still get goose bumps when I reflect on their sacrifice.

  No, we didn’t know the pandemic of our lifetime was already forming and gaining strength a world away as Coppola and I enjoyed that pleasant, peaceful New Year’s Eve. We joked that the story unfolding might be something Coppola could put his own spin on, like some modern-era version of Apocalypse Now. But neither of us believed anything like that would really happen.

  “In the beginning, you just never know with these things,” I remember telling him somewhat nonchalantly at the time.

  We also talked about another movie that might have foretold the year we were about to endure. In 2011 I had a small role playing myself in the blockbuster thriller Contagion. (That’s the one where Gwyneth Paltrow’s character brings a new pathogen home to Minnesota from Hong Kong, has a grand mal seizure in the kitchen, and ends up dying horrifically in the hospital.) I recently revisited the script of my scene with the fictional head of the CDC, Dr. Ellis Cheever (played by the great Laurence Fishburne), and was struck at how prophetic the filmmakers really were.

  Me: There are stories circulating on the Internet that in India and elsewhere the drug Ribavirin has been shown to be effective against this virus. Yet the Department of Homeland Security is telling the CDC not to make any announcements until stockpiles of the drug can be secured.

  Dr. Ellis Cheever: Well, Dr. Gupta, there continue to be evaluations of several drugs. Ribavirin is among them. But right now, our best defense has been social distancing. No handshaking, staying home when you’re sick, washing your hands frequently.

  Sound familiar? Ribavirin is a fictional drug, but the buzz about hydroxychloroquine early on during the pandemic—and the politics swirling around its messaging—eerily parallels the movie’s storyline. And Dr. Cheever’s remarks about social distancing, handshaking, staying at home, and washing hands became a part of the world’s daily dialogue. It was as if the writers had some access to an oracle, but the truth is it was a deep-rooted knowledge of science. Dr. Cheever’s character even mentioned how difficult
it was to know the actual death count, as well as the trouble with having “fifty different states… which means there are fifty different health departments followed by fifty different protocols.” The night before filming began, the screenwriter, Scott Z. Burns, and director Steven Soderbergh had dinner with me to talk about their sci-fi movie, which they said was based on existing public health models readily available all over the world.

  There is no doubt we had all sorts of warnings, and even Hollywood movies, to raise the alarms of what might be coming. The models used for Contagion accurately predicted that a novel virus would momentarily become the top cause of death in the United States, ahead of heart disease, cancer, and strokes. That it would bring down life expectancy a full year in the United States and at the same time lay bare the tremendous disparity in our health care system as the Latinx community lost two years of life and Blacks lost nearly three.3

  It is hard to fathom that a microscopic blob of genetic material with no brain, eyes, ears, limbs, wings, heart, or emotions could inflict more harm than armies of soldiers in the midst of massive conflict. But SARS-CoV-2, the name of the new coronavirus that causes the wide-ranging disease named COVID-19, did just that, arriving like an alien invader and declaring war on planet Earth.

  While most wars start with a declaration of sorts, World War C had a blurry, undefined, clumsy whisper of a beginning that will probably be debated for decades. We don’t yet know exactly when or how this particular contagion of likely bat origin jumped into human circulation and gained such unprecedented power, speed, and virulence. What we do know is that by January 5, authorities in China and neighboring countries were publicly worried. They raised the health threat alert to Level III (Serious) in the face of a “pneumonia of unknown origin.”4 We’d all eventually find out that the disease was caused by a coronavirus, a type that belongs to a family of viruses known to cause a variety of respiratory, gastrointestinal, and neurological diseases.

  A story I learned early on and that remained buried in the medical literature also happened that same January day. A sixty-one-year-old woman living in Wuhan had developed fever with chills, sore throat, and headache; she visited a local health facility for help and was given some medication that probably had no real effect on her fomenting illness.5 Despite that, a few days later, on January 8, she took a direct flight to Bangkok, Thailand, from Wuhan City with five family members as part of a tour group going there to celebrate the Lunar New Year. I can tell you from personal experience, Bangkok’s Suvarnabhumi Airport has one of the best surveillance systems in the world for detecting sick travelers to their country, so it was no surprise that her fever was immediately flagged and she was taken to a hospital. It was at that point she was found to be infected with the novel coronavirus. Although it was initially thought she was among the first people to unknowingly export the virus outside of China, newer reports show that people in the United States had already been infected by then, and likely weeks previously. In other words, the new coronavirus was infecting Americans long before the world knew it was causing a deadly outbreak in Wuhan.6

  Let me pause here to consider the following: If you or I had flown on that same day to any major airport in the United States with flu-like symptoms, chances are that nobody at the arrival gate would’ve even blinked, let alone taken our temperature, or asked any questions. It was very different in many Asian countries, where they have been dealing with the threat of aberrant new viruses (with pandemic potential) for much longer than we have. The SARS outbreak nearly two decades ago was in many ways a frightening sneak preview—as well as their incentive to implement very strict public health measures.

  Interestingly, the sixty-one-year-old sick woman regularly visited local markets in Wuhan before falling ill, but had not been to the Huanan Seafood Market, which was being described as the origin of the outbreak. Her case instigated international tensions between the two countries as it forced China to disclose to the world it had a problem. Once Thailand had isolated the patient, taken samples of the virus, and identified its genomics, Bangkok called Beijing and put pressure on China to confess their secret, or else. China initially refused, instead demanding their sick citizen back—as well as the genome sequence that Thailand now possessed. The exchange, which I learned about through an epidemiologist friend of mine who demanded strict anonymity, went something like this:

  Thailand: You have a problem you have to tell the world. We’re going to release the genome sequence and publish it unless you do.

  Beijing: She’s ours. Give her back to us—and the sequence.

  Thailand: Fuck you.

  By the time the United States seriously clamped down on incoming passengers from China on February 2, hundreds of thousands of people had already traveled from China to the United States, and millions more around the world. We watched as China locked down domestic travel at the end of January but left foreign travel open. While this strategy may have reduced the spread of the coronavirus within China, it did nothing to curb the viral explosion worldwide.

  In a January 28 top secret intelligence briefing, national security adviser Robert O’Brien gave President Donald Trump a “jarring” warning about the virus, telling him that it would be the “biggest national security threat” of his presidency.7 He also told Trump that it could be as bad as the influenza pandemic of 1918, which had infected half a billion people and killed an estimated 50 to 100 million worldwide, including 675,000 Americans. It was also the first time the administration was alerted to a critical detail: the possibility of asymptomatic spread. That is, many of the people transmitting the virus appeared to have no symptoms, and thus no clue they were infected.

  Despite that, the initial response in our country was still based on influenza modeling, where people are considered sick only when they show symptoms. That would prove to be one of the most disastrous mistakes of the whole pandemic. In other words, even as we started to respond to the outbreak, we were essentially treating the wrong disease. At the time we were reporting cases of a few dozen sick people, there were probably already thousands of symptom-free people unwittingly spreading the virus as Americans went about their normal lives.

  Most of the news stories were filled with the impeachment trial and Kobe Bryant’s shocking death in a helicopter crash outside Los Angeles. It was only after the first US case of human-to-human transmission on home turf was confirmed on January 30 that the White House took more decisive action, issuing a Level 4 travel advisory for all of China and declaring a “public health emergency” the next day.8 A Level 4 advisory is the highest advisory level, indicating a greater likelihood of life-threatening risks. The message was now clear: “Do Not Travel” to that country or leave as soon as it is safe to do so. Even then, public health experts were split about the effectiveness of restricting air travel. While they had spent their entire careers preparing for this very event, few of them had ever experienced anything like it for real. It was as if they were well-trained police officers hesitantly drawing their weapons for the first time.

  As more information slowly trickled in, the level of anxiety in the public community started to fire up. Normally tempered experts increasingly used uncharacteristically hyperbolic language. Harvard-trained epidemiologist Dr. Eric Feigl-Ding’s first viral tweet had already gone out on January 24 and generated him an instant following: “HOLY MOTHER OF GOD—the new coronavirus is a 3.8!!! How bad is that reproductive R0 value? It is thermonuclear pandemic level bad.…”9

  Like the magnitude of an earthquake on the Richter scale, the R0 (pronounced “R-naught”) is a mathematical measure of a disease’s reproduction rate; it’s an average measure of a virus’s transmissibility but can be affected by lots of factors, including local policy, population density, and even the weather. Hence, the R0 for COVID can differ across the globe and change over time. As a comparison, the R0 of measles is 12 to 18, by far the highest known to humans, and the R0 of seasonal influenza is around 0.9 to 2.1. As Dr. Feigl-Ding tweeted, th
e available data at the time revealed the R0 for COVID to be somewhere between 1.4 and 3.9. That meant every single person infected with COVID could spread it to up to four others. If the R value is less than 1, an epidemic quickly dies out because each infected person generates fewer than one new infection. While some criticized Feigl-Ding for his tweet, many hailed him along with several others as being the Cassandras of COVID—those who uttered the truth but were never believed.

  As a medical reporter at an international news network, I knew that my globe-trotting days would be suspended as I was forced to retreat to my compact home basement to report around the clock on every aspect of the novel coronavirus—how it travels and transmits, the molecular keys it uses to gain entry into cells, and what havoc it causes once inside the human body. And when it became clear several months into the pandemic that COVID-19 was causing neurological deficits, from minor ones like temporary loss of taste and smell to more serious problems like stroke, dementia, and psychiatric disorders, my worlds of brain surgeon and medical correspondent came crashing together.

  By one large study’s calculation, a third of patients diagnosed with COVID-19 experienced a psychiatric or neurological illness within six months.10 And, more than a year later, this novel coronavirus continues to surprise us. We still don’t know why some people have barely any symptoms while a similar person might end up in the ICU. We aren’t sure how effectively the body clears the virus and what the persistent effects might be in those infected, including children. After this pandemic is one day declared officially over, we will likely be dealing with millions of people managing COVID-related symptoms long term, patients who are known as the long-haulers.

  For more than a year, I had to wake up and steel myself every day to deliver tough news to a global audience. I would’ve rather been talking about extraordinary advances in science and telling stories of cultures living long, happy lives. Instead, it was a continuous narrative of increasing infections, hospitalizations, and deaths. While my medical training did prepare me for the heartbreaking task of delivering awful news to patients and their families, it never gets one bit easier, even after decades of doing it. In these tough situations, whether in medicine or media, I have tried to live by a few rules. Listen as much as you talk, and when you do speak, make sure you are understood. Speak clearly, slowly, and with great empathy and humility. You have to constantly remember that your words are fundamentally changing the course of your patient’s life. It is as important to explain what you don’t know as it is to be clear about what you can say with certainty. There is a balance between hope and honesty. Honesty should always lead the way, full and transparent, but hope has deep value as well. Hope is not a strategy, but it’s a damn good positive motivator. And finally, whether it is speaking to a patient one-on-one or trying to educate a global audience of concerned viewers, I am always reminded of a quote from the great Maya Angelou: “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”11