Looking back at COVID-19

(A few additional comments added on 02/21/21)

COVID-19 is still a menace that is affecting thousands of people every day across the globe. However, vaccination and palliative therapies indicate that there is less of it ahead of us than behind us. I am training in pathology at a hospital in Texas and do not have the required qualifications to talk about the nitty gritty of COVID virus and its structure. However, I was involved in management of patients with COVID who were in intensive care and before that, in procuring convalescent plasma for COVID patients. I want to write about the policy and public health side of managing COVID and not the clinical perspective, which is not my primary specialty. This piece was inspired by two articles in the New Yorker, the first is a long-read from Lawrence Wright (here) and the second is from Charles Duhigg (here).

When news about COVID started trickling at the end of December 2019, I was not alarmed. I thought of SARS, Swine flu, Ebola and MERS, which were mostly containable viral diseases and their human impact was not global. I was at a conference in Dallas at the end of January, where a presentation was on memories of dealing with the first Ebola case in the US. I remember sitting in the back row of the auditorium and listening to the lengths that a particular hospital in Dallas went, to quarantine the said Ebola patient. By February, there was news of how Chinese state was hiding things about the mysterious viral infection and whistleblowers were shedding more light on the disease. It was in late January-early February that first cases of the mystery virus were discovered in Seattle suburbs and suppression of data/news about COVID started in the US (the Trump administration). I was at another conference in Los Angeles at the end of February and saw the news that cases of COVID had been diagnosed near San Francisco.

Upon my return to work in the first week of March, I was required by the hospital to report travel to the employee health clinic, which I did. Prior to arrival of COVID, I was going to travel to Ohio for an elective rotation and to New York to present at a conference. With COVID, all plans had to be cancelled. Since March of last year, COVID has affected millions of people across the globe and disrupted life as it used to be. One of my friends refers to any year before 2020 as “X years B.C.” (before COVID).  Moving from my personal story to a bird’s eye view, what can we learn from COVID moving forward? I have tried to distill my thoughts about the pandemic, pandemic response and best practices.

Based on what we know now, here are a few things about COVID response, with relevant exceptions:

1. Island nations have generally done better, with exception of Britain and to an extent, Vietnam. At the start of the pandemic, there were fears that autocratic governments will prevail better because dictators don’t have to worry about human rights, laws or courts. That fear has not come true, generally. Australia, New Zealand, Taiwan, Sri Lanka or Vietnam are mostly democratic nations.

2. Things have been better when scientists and public health officials have been allowed to be at the forefront, except in the case of Sweden, where the top epidemiologist wanted to test his “herd immunity” theory.  The New Yorker story from Charles Duhigg that I mention above, refers to a significant difference in COVID cases and deaths between New York, where politicians were at the forefront of COVID response, versus Washington state, where public health officials made the rules.

3. African nations have done better at managing COVID than most ‘first-world’ countries, in my opinion, due to their experience in dealing with Ebola, MERS and similar viral illnesses. There has been a recent second wave and a South-African variant that is more resistance to the mRNA vaccines than the OG COVID-19 or the UK variant. There was a recent story in the BBC about the second wave (here) and earlier, about the low rates of infection and mortality in the African continent (here).

4. It is incredibly hard to restrict what constitutes “daily life” even in the face of a deadly pandemic. Human beings are social animals and severing that connection from others, whether in form of closing offices or bars and restaurants, cannot be reliably depended on for long periods. Travel has become another necessity in this day and age, for business or pleasure. Airlines and the hospitality industry as a whole will be running losses for years to come. I traveled three times during the last year, twice domestically and once on an international route. I tried to be cautious and got tested before/after each of these journeys, which, admittedly is not a perfect way of being safe from COVID. There were multiple studies about spread of COVID on airplanes and I was constantly in fear of contracting it while flying, despite all precautionary measures.

I do not frequent bars/clubs in general so i didn’t miss them much. However, I did miss spending time at the library and our nearby Barnes and Noble.  If one were to look at the graphs of cases and deaths in the US, there are peaks around memorial day, 4th of July, Labor day, Halloween, Thanksgiving, Christmas and New Year. Around Christmas, close to a million people were flying every day in the U.S. Graphics from the Washington Post tracker.

5. China, not completely culpable but deserves blame for its early missteps and obfuscation (a la Great leap forward) when it comes to COVID. We still don’t know if COVID transmission started at a wet market or somewhere else. Wuhan is back to pre-COVID times while the rest of world keeps suffering. Chinese authorities have tried to strong arm the WHO and any outside effort to investigate the origin of transmission of COVID. I do not subscribe to the conspiracy theory that COVID is a “China virus” or that it was manufactured in a Chinese laboratory.

6. Vaccines. I consider the development of COVID vaccines a modern day miracle. The fastest that a vaccine had been previously prepared was close to three years. The severity of disease, mounting death rate and irresponsible behavior by the general public, made the timeline for introduction of a vaccine shorter than ever. Fortunately, the mRNA type platform vaccines had been in development for years and this was the right moment for them. The journey started in January 2020, when COVID genome was first shared by Chinese scientists and culminated in November/December 2020, when two major candidate vaccines was ready to be administered. Since mid-December, more than 73 million doses of either of these vaccines has been distributed in the US. This is a graphic from the Washington Post tracking vaccine distribution in the US:

I got vaccinated in January and feel fortunate to have that immunity. However,  the mRNA vaccines have a 66% response to the South-African variant (versus 90-95% against the OG COVID).  The AstraZeneca vaccine has a 23% immune response to the South African variant. There is very little good data on vaccines developed by Russia, China and India. From what we know about their mechanisms of action, Russian vaccine is similar in mechanism to the AstraZeneca vaccine (uses inactivated Adenovirus), while the Chinese vaccine is based on inactivated virus and the Indian (serum institute version) uses live attenuated virus. Graphic from NEJM.

7.  Viruses don’t care about state or national boundaries. The Sturgis motorcycle rally in South Dakota in August led to increased cases in neighboring Minnesota (here). A single conference in Boston in Feb 2020 lead to almost 300,000 cases (here). COVID has reached Antarctica, the last bastion of human presence without infection (here).

8. Disinformation spreads faster than the truth. The famous line that “A lie can travel halfway around the world before the truth can get its boots on” was truer during the COVID pandemic than any other modern peacetime event. Since I have a medical degree and had some exposure to COVID response, I was asked by many family members and friends from across the globe about various conspiracy theories circulating regarding COVID. The top hits included COVID vaccine altering your DNA, different cocktails for treating COVID (the whole hydroxychloroquine debacle), herd immunity, exaggerated vaccine side effects, masks, Vitamin D, COVID vs Flu, PCR vs rapid testing and their predictive values, various miracle cures etc. Many of these lies and misinformed views were spearheaded by medical personnel (doctors, nurses, nurse practitioners etc) which made it incredibly hard for a layperson to know what was the truth and what was just a fanciful conspiracy theory. To top it all off, many people initially (and still) refuse to believe that COVID is real.

9. Masks work but not all masks are the same. This is related to point 4 from earlier (human nature cannot be suppressed for long). It is hard to wear a mask all the time. I work at the hospital and that being a high-risk area, everyone has to be masked almost all the time. But, due to strict masking requirement, infection rate of workers (both medical and non-medical) at our hospital stayed less than 1% even when the infection rate was close to 10% in the community that we serve. N95s which should be worn by individuals who are at the highest risk of getting COVID provide better protection than a regular surgical mask (efficacy close to 65%), which is better than a regular cloth mask (efficacy less than 50% and needs to be washed regularly). I have seen innumerable number of people wearing their masks incorrectly (i.e. nose not covered) but I think that at least they are wearing a mask. One reason that east asian nations did better at controlling the pandemic is because mask-wearing is normalized at a larger societal level, compared to “freedom from tyranny” type attitudes seen in the US. According to estimates, if 90% people in the US had worn masks at the beginning of COVID, we could have averted millions of cases and thousands of deaths.

In Arizona, there were dramatic improvements in case numbers once mask mandates were enforced. (paper from CDC here).

10. The curious case of Pakistan and India. Early in the pandemic, while COVID was running rampant through most of Europe, North America and South America, India and Pakistan had very few cases compared to their populations. While India has caught up with the rest of the world lately, Pakistan is still reporting less cases than any major city in the US per day. What is causing this divergence? There are many theories and until it is studied methodically, I don’t have a clear answer. Even people who got COVID in Pakistan, got a mild disease. Many people pointed to BCG vaccination as being semi-protective against COVID. Some commentators proposed immunity due to earlier sub-clinical viral infections. Are there genetic factors causing this? My hypothesis is that Pakistan is not as exposed to the outside world as lets say the United States is. Secondly, testing in Pakistan is at a much lower level than anywhere else. At one point last year, the state of Punjab, with a population larger than Germany, was doing close to 15,000 COVID tests a day. If you don’t test, you can’t diagnose. Cases in Pakistan and India, graphs from the Johns Hopkins dashboard.

11.Personal Responsibility. The mantra of personal responsibility has been used throughout the pandemic by mostly right-wing politicians, trying to avert blame from themselves, resulting in a terrible failure. Anyone who has ever worked in customer relations can tell you that most people don’t really care about other people (knowingly or unknowingly). Public health does not work that way. One can argue that even economics doesn’t work that way either, but that is a separate debate.

12. One heard the phrase “how many lives can you save by closing the economy” or variations of it since the early days of the pandemic. The lives versus economy rubric was debated over and over, without much evidence. Countries in the EU and Australia/NZ paid people to stay home. That approach is paying them off in the long run. In a paper titled “COVID-19 and global income equality” (here), Angus Deaton showed that saving lives has a positive impact on long-term economic outlook of a country.

13. Is the “office space” dead? Are we going to have a different economy after the pandemic? Would there be mass migration from major cities towards smaller towns and suburbs? I don’t have these answers as I am not an economist or a public planner. But these questions interest me and I am always trying to read about them.

14. Lastly, I cannot predict what is going to happen with COVID. When the pandemic started, my hope was that it would die down within six months. With a sharp decline in case numbers and increase in vaccinated individuals, I have hope that COVID would be under control by the end of the year. Would new variants disrupt this timeline and everyone will have to get a booster vaccine at some point in time? It is quite likely.

Comments and suggestions welcome!




16 Replies to “Looking back at COVID-19”

  1. Good Summary.
    Indian vaccine is made by Bharat Biotech and not Serum. Serum is just the manufacturer (not developer) tor AstraZeneca and Novavax.

    Even inside India difference in covid between Maharashtra/Gujarat/Kerala and UP/Bihar are 4-5 fold. For India Pakistan I would say (more true for UP Bihar) large young populations could be the first line of defense

  2. Until last year, I didn’t realize how much a lot of people hated going to work (physically, that is). Probably to most people, their office is The Office. At least, that’s what I’m getting from the reams of opinion pieces heralding (mostly gleefully) the demise of the office space.

    As in so many ways (as many can observe from the tenor of my comments on BP), I’m an exception to this too. I liked going to my office. It was my daily diversion and it was literally my entire social life. It’s the only thing I’ve really missed in the pandemic.

    I never used to go to bars or clubs, and rarely to restaurants and movie halls, so I don’t give a damn about them. But I really hope we get our offices back. If not, life will suck!

  3. I think credentialism took a major hit during the pandemic. In Europe, there is deep seated suspicion and animus towards the authorities. This will wash over into the elections. Many parts of Europe are still in lockdown – it is unimaginable for Indians.

    The Lowy Institute study is rather unmodified for scale and density. Looks like it is skewing towards – 1. Islands 2. Countries with low population density 3. Strong societies (SE Asia)

    There is a very good substack from Dr Praveen Patil on 2020 and what he calls the “casedemic” and the overscaled diagnostic mechanism of the PCR test.


    1. I think credentialism took a major hit during the pandemic.

      You may be right. But I hope people are able to distinguish the credentialed people spouting off on public policy, who have turned out to be more wrong than right, from the credentialed people who have played a stellar role in advancing microbiology and medicine, giving us a chance of surviving these things in a way that would have been unimaginable for people who went through the 1918 flu pandemic, let alone the Black Death.

      In the US especially, there is a curious conflation of higher degrees, and a blindness to the serious difference between someone who obtained a PhD in, say, sociology, vs someone who obtained a PhD in, say, virology. I, as a CS PhD myself, may be biased, but the rigor that goes into gaining expertise in a STEM field cannot, I think be matched by that in a humanities PhD. Especially since all humanities disciplines in higher education seem to have succumbed to the language of critical theory.

      1. @Numinous

        Perhaps it could be that a pandemic is a societal problem rather than a medical problem. The multi-dimensionality was clear in January 2020 when Trump was thinking about a travel ban to and from China. Almost all off the mainstream media ran articles about the dangers of xenophobia. In Italy, some morons organized a “Hug a Chinese” campaign especially tourists who were just fresh off the plane.

        This pandemic merged political, economic and tech worlds into one box. STEM credentials mattered little at the start but then two months down the line, political decisions were disguised as STEM logic. Every opinion piece I read were political pieces hiding behind STEM language. The hit jobs on HCQ just because Trump backed it is just one example.

        Perhaps time has to pass in order for people to confront the mirror.

    2. @Ugra
      The post goes on to talk about Vitamin D and Ayuverda as possible cures for COVID, these things have been repeatedly disproven as any type of cure or even for ameliorating the symptoms of COVID. Same for Hydroxychloroquine (which has its legitimate uses, just not in COVID). The post doesn’t talk about rapid tests (which are not RT-PCR). At our hospital, 99% testing is done rapid (as our PPV for rapid is as good as RT-PCR). Faulty assumptions, faulty analysis.

  4. China is hiding something. Very likely the virus escaped unintentionally from the virology labs in Wuhan – which has 2 major labs- into the Wuhan Seafood market. For example , many test animals may have been carelessly disposed off
    To cover their tracks, the Chinese govt is spinning tales of how COVID originated in US or Europe. The official Chinese line is COVID did NOT originate in China and all Chinese people including all scientists and doctors have to sing from the same hymn book .
    BTW, the cases in India are remarkebly low now is spite of tardy social distancing or masks

    It is a measure of how remarkable the adavances in the medical field is that COVID vaccines were developed within the same year and made available in the same year

    Even in March/april 2020, many people were saying it will take 18 months to develope a vaccine

  5. There has been remrakable differences between Spanish Flu of 1919/20 and COVID of 2020.

    100 years back, about 50 MILLION people were dead in the Flu epidemic , about 40 million in the India i.e. British India. It is a measure of how much the government capacity and the medical research and production capacity has increased all over the world that COVID deaths has been confined to 1 million, maximum 2 million.

    One side effect of COVID pandemic and the resulting government action in the financial and economic fields is that the gap between Very rich and mass of people has grown enormously within 1 year. This is what people call K Shaped recovery i.e. rich get richer, poor poorer

    COVID destruction of status quo economic landscape has accelerated adoption of newer technologies like internet, electric cars, gene editing and genomics, etc. It has also given rise to some amount of de Urbanization as people leave big cities in droves for countryside and work from there

  6. Minor nitpick but Vietnam is not democratic.

    I think less cultural emphasis on individualism and higher trust in government really helped east / sour East Asian countries.

    1. Yes, Vietnam is not democratic. But it is an exception, rather than a rule, in terms of countries having controlled COVID better.

  7. This summary is ok but pretty one-sided as almost all contributions from subcontinent. They are American (or British) centric and even all articles about ancient SA history are cited and commented, discussion is exclusively about western Christianity, etc. It is off this topic but even regarding current happenings in US, most of SA diaspora can’t see what is really happening there or those who can see are afraid to talk. I would suggest pundits that from time to time throw a glimpse on the Globus.

    So as in the case of vaccines. There are no critical presentations about Pfizer (i.e. Turkish-German) vaccine, their untested technology and their pretty suspicious commercial dealings in the last year. There is no much information about 3 (three) registered Russian vaccines which apparently have the highest success and the longest protection. There is also no information about very interested case about Belorussia, only country which did not have any measure (Sweden had some), they played soccer games with public, no public restrictions, even protests had 100+ K of people and all this without detrimental effects. Maybe it is out of the scope but we can’t see political aspects of Covid, B.Gates’s pandemic dress rehearsal one month before it was registered in Wuhan, about direct link ‘Great Reset’ leaving an impression that all these were parts of the same master plan, etc.

    1. I am not going to respond to some of your more outlandish, conspiracy theory laden comments. I did mention the Gamaleya vaccine and you can read more about it here: https://www.newyorker.com/magazine/2021/02/08/the-sputnik-v-vaccine-and-russias-race-to-immunity

      Comparing a vaccine to a notorious weapon such as an AK-47 is not a really scientific way of looking at things or a good mode of public health communication. Sputnik V is similar in action to the AstraZeneca vaccine which has shown lowered immune response to the South African variant.

      An excerpt from the NYer article on the Gamaleya data published by The Lancet: “Three days later, an open letter, which has since been signed by almost forty scientists, mostly from prominent Western research centers, pointed out a number of supposed irregularities with the data. Most significant, the reported antibody levels of participants looked strangely similar. “On the ground of simple probabilistic evaluations the fact of observing so many data points preserved among different experiments is highly unlikely,” the letter read. One of its signatories, a Russian-born molecular biologist at Northwestern University named Konstantin Andreev, told me, “We weren’t saying whether the vaccine is good or bad, safe or unsafe. Our objection wasn’t really to the vaccine per se but to how the researchers carried out their study. At minimum, it was sloppy; at most, it was manipulated.” The signers of the letter requested the raw data from the trials so that they could draw their own conclusions.

      Logunov and his co-authors replied in The Lancet, saying that any repetitive figures were the result of simple coincidence, the small number of participants, and lab instruments that distribute values into discrete clusters. They declined to provide the raw data. Logunov told me that to give such information to anyone who asked for it would be a distraction, and a violation of the norms and practices of modern pharmaceutical development. “There are seven billion people on earth, and it’s impossible to present every data point to everyone,” he said. “No one works this way.””

  8. It is difficult to get recognition from Westerners directed to Serbia or Russia. It only arrives when the English, Americans or Germans are forced to do so or when they calculate that they can profit from it as well.

    There are, however, rare exceptions. The chief specialist for infectious diseases at the Medical University in Vienna, Florian Talhammer, the chairman of the Austrian Society for Infectious Diseases and Tropical Medicine, stated that the Russian vaccine against covid-19 “Sputnik V” showed efficiency and reliability like the famous Kalashnikov assault rifle:

    “That vaccine is really like a Kalashnikov assault rifle: simple, reliable and effective.” This was confirmed by the data published in the esteemed professional journal. It’s a little late, but it doesn’t matter. ”

    Sputnik V was registered in Russia in August 2020. It was produced at the Gamaley Research Center. On a well-studied and validated platform of human adenoviral vectors. The British scientific journal The Lancet published the results of the third phase of its clinical trials, which confirmed the efficiency at the level of 91.6 percent. The Austrian government is considering Russia’s proposal for local production of the Russian vaccine.


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