Covid-19: will we learn the lesson for the future?

Reflections by the immunologist Václav Hořejší on how the current situation is being handled.

The present pandemic is a heavy blow to the whole world — and, somewhat paradoxically, above all to its richest and economically and technically most developed part. That something of this kind would strike us has been known for a long time; the only questions were when it would happen and which particular virus it would be. It is therefore shocking that the new coronavirus caught us rich "Westerners" in particular so desperately unprepared and caused us so much damage.

A brief recap

The covid-19 pandemic has been with us for more than a year. It is still not known what the origin of the SARS-CoV-2 virus that causes the disease is, and it will very probably never be known exactly. There are evidently very many already known coronaviruses in nature, and certainly still more as yet unknown ones; their main known reservoir is above all bats (the question of why these viruses do not harm those creatures is very interesting, and essentially already answered).

It is very likely that the first jump of the virus from an animal (perhaps a bat) to the first human did not occur at the famous Wuhan market, but most probably much earlier and in an unknown place. The first traceable cases, from November 2019, have nothing to do with the market. There are reports of unexplained cases of viral pneumonia from several places in the world during 2019. The first, possibly quite distant infection of a human probably led to unnoticed limited spread of the virus in the human population; at first it was not very well adapted to its new host and therefore spread slowly and perhaps caused only mild symptoms. Over time, however, mutations optimised for the human host may gradually have appeared. Someone infected with such a variant of the virus could simply have turned up at the market, where conditions were ideal for the virus to spread and for an epidemic to begin. During December a number of cases of pneumonia appeared in Wuhan, and at the end of December some local doctors suspected that it was a disease similar to SARS, which had spread through East Asia in 2003. At first, however, it was not clear whether this disease spread from person to person. Local authorities and police therefore feared premature panic, so information about the illness was withheld and the necessary anti-epidemic measures were not taken in time. Chinese scientists identified the cause of the epidemic as a new coronavirus on 5 January 2020 and published its complete genome a week later, while human-to-human transmission was only definitively confirmed on 20 January. The World Health Organization (WHO) at first issued mild warnings and did not describe the risk of an epidemic at the global level as high until 27 January. It began to be clear that the fatality rate of the disease was evidently much higher than that of influenza. From 23 January the Chinese government imposed a strict two-month quarantine in Wuhan and other surrounding cities, affecting more than 60 million people in all.
Many people now accuse the Chinese of underestimating the situation, of adopting the necessary measures late and thereby causing the coronavirus to spread across the world. It is true that they could have begun the quarantine a little earlier, but the fact is that their first patient did not die until 11 January. It is perhaps understandable that they did not want to resort to drastic measures until it was clear how genuinely serious the disease was and how it spread. The WHO's response also seems to me broadly proportionate to the information available to it. On the other hand, the Chinese behaved entirely transparently in publishing the complete sequence of the viral RNA very quickly in a leading international journal, thereby enabling anyone in the world to develop rapid tests for the presence of the virus and to develop vaccines.

There is, however, also a widespread suspicion that the virus escaped from the laboratory of the local virology research institute, where coronaviruses really were studied systematically over a long period (in cooperation with a number of prominent foreign researchers). Work there even involved artificially altered variants of the closely related bat virus RaTG13, and it was investigated which of them could infect human cells. These "gain of function" experiments, aimed at better understanding potential human pathogens and identifying their weak points, had long been criticised by some scientists as too risky (because of the possibility of an accident in which the virus might escape from the laboratory and cause an epidemic). Prominent among the supporters of the theory of a laboratory origin for SARS-CoV-2 is the former American vice-president Pence, who a few months ago even declared that he had clear evidence of it, though he has so far presented none.

It has to be acknowledged, though, that the hypothesis of a laboratory origin for the virus is legitimate in principle — using methods known today, any virus of this type can be created relatively easily in a laboratory anywhere. As a result of some laboratory accident or carelessness, an artificially created variant almost identical to what we now call SARS-CoV-2 could easily have escaped. But there is no direct evidence for this hypothesis — such evidence could probably only be supplied by people who had been involved in some such hypothetical concealed accident. Without clear evidence it simply remains a hypothesis, one that naturally attracts great attention for political reasons among others.

Whatever the origin of the new coronavirus, what is fundamentally important is the lesson to be drawn from how different states responded to the pandemic. The Chinese used a truly drastic but effective method — for two months they subjected over 60 million people to a strict lockdown, in which people were not allowed (apart from absolutely essential exceptions) to leave their homes, not even for work. Other Asian countries (South Korea, Taiwan, Vietnam, Thailand, Japan), but also Australia and New Zealand, quickly closed their borders, tested intensively for the presence of the virus in the population and introduced effective anti-epidemic measures (bans on gatherings, wearing of masks). They thus managed to suppress the epidemic almost entirely and so to minimise the economic damage too. This prompt response was certainly also a consequence of these countries' experience with the earlier epidemic of the related disease SARS in 2003.

Compared with this rational and effective approach, the hesitation of the great majority of developed Western countries is incomprehensible. Surely we had to see that this was something very serious when the Chinese did not hesitate, already in January, to place over 60 million people in strict quarantine! And yet for several weeks the Europeans neither banned flights from China nor adopted basic preventive anti-epidemic measures. The consequences were not long in coming — the epidemic broke out quickly, first in Italy and then in other countries. The Czech government, however, responded successfully, indeed exemplarily, in March 2020 — as one of the few "Western" countries. During the spring we therefore had only a little over 300 deaths from this disease. Paradoxically, it was precisely this success that was belittled by some critics among economists and, unfortunately, among some doctors too. The critics complained that the government had blocked the economy and caused great economic damage over a disease from which a mere 300 people had died. It is incredible that these educated and intelligent people refused to understand that the low number of deaths was precisely the result of the measures adopted, without which it would have been many times higher. And the lament over the "hard shutdown" of the economy was also largely false — all manufacturing sectors operated almost normally; only the service sector was hit hard.

Given the very good situation, at the beginning of July all anti-epidemic measures were lifted and it seemed we had won — there would be mass testing, we would watch for possible imports from abroad, a system of a kind of "smart quarantine" would start working, small local outbreaks would be easily eliminated and the virus would practically disappear from the population (it later turned out that this approach really did work very well in Finland and Norway, for example).

All restrictive measures were lifted from 1 July and people set off on holiday across the Czech lands and abroad. At the end of the summer holidays, however, case numbers began to rise, and the government, perhaps fearing that people would be angered by the reintroduction of irksome restrictions, remained inactive. Unfortunately, the prospect of the approaching autumn elections almost certainly played a negative role too. And the government had a good excuse in the publicly presented positions of a number of medical, economic and artistic celebrities, who assured the public that the spring anti-epidemic measures had been excessive, unnecessary and had merely damaged our economy. The necessary measures were adopted in the end, but only late and hesitantly, so the epidemic got out of control and the result was the autumn wave, peaking at the beginning of November. Around 10,000 people paid for it with their lives.

Just when it seemed that this wave would be brought under control, Christmas began to approach. And the government again behaved in its "tried and tested" way — anti-epidemic measures were relaxed so that people could do their shopping before the holidays and enjoy themselves a little. The result is the current drawn-out third wave, which brings 100 to 200 deaths every day and is putting an overstretched health service in a difficult position. Over the past few months the Czech Republic has reached a sad leading place in the world in covid deaths per head of population. It may be some small consolation that some other developed countries handled the first wave, and repeatedly the second, no better. By contrast, almost all Asian countries, and also the Scandinavian ones (apart from eccentric Sweden), continue to manage the situation in exemplary fashion.

Vaccination

Worldwide, vaccination against covid appears to be the way out. The speed with which vaccines were developed was truly unprecedented, and it also proved possible to minimise the time needed for testing and approval. Two things were of fundamental importance here: that these were new types of vaccine, whose mass production is easier, but also that the pharmaceutical companies that entered the development race received exceptionally generous financial support from public funds so that they would not be exposed to the risk of losses in the event of failure. Vaccination is now under way; furthest along are Israel, the United Arab Emirates, the USA and the United Kingdom. It is sad that the EU is lagging behind, because it was unable to negotiate better agreements on binding deliveries from producers.

Somewhat unexpectedly, however, a certain complication has appeared — much more infectious variants of the virus have begun to occur, but also variants partly resistant to the vaccines in use. There is therefore a risk that achieving effective herd immunity will require a much higher level of vaccination coverage than has been assumed so far, and even that vaccinated people might not be relatively safe. A state of herd immunity is needed so that those in whom vaccination was not sufficiently effective are protected too.

Vaccination is important not only for at-risk groups (the old and the chronically ill) but for the young and healthy as well. It is becoming clear that even after a mild form of the disease these people quite often have serious long-term complications, so-called "long covid". Covid (and influenza too, for that matter) therefore must certainly not be underestimated even in young and healthy people, including children.

We do not of course yet know how long immunity to covid induced by vaccination will last, but it is reasonable to assume it will be at least two years. It is quite likely that immunity induced by vaccination will in fact be more lasting than that following the illness — all this, of course, only if it is not complicated by those "escape", resistant variants of the virus. Even that, though, could be managed by repeated booster vaccination. Only that would reduce the probability of ever new mutations of the virus arising and spreading that are resistant to vaccination against the "standard" forms.

In this connection it is very interesting that in some developing countries (India, most African countries) the number of covid cases, and above all of serious cases and deaths, is relatively low. The cause is probably mainly a different demographic situation — compared with developed countries there is a far larger proportion of young people, in whom the course of the disease is relatively mild and mortality comparable to influenza. The exposure of these populations to other pathogens may also play a role, which may "non-specifically" strengthen immunity. It is not clear, though, why this evidently does not apply to the South American population, where covid is raging at least as intensively as in Europe or North America…

Deniers, doubters and the weakness of the state

In the Czech Republic (but in many other countries too) the attitude of a considerable part of the public to anti-epidemic measures and to vaccination is unfortunately sceptical or even plainly hostile. The voices of those calling for the existing measures to be lifted make themselves heard. And these are not only publicans and ski-lift operators, whose businesses really are hard hit, but also some doctors and economists popular with the media, who promote the strategy of "natural herd immunity" among the younger and healthier part of the population — a strategy repeatedly refuted and discredited by experts. An utterly appalling case is the conduct of the former president Klaus, calling for "civil disobedience" and accusing hospitals of falsifying the real situation. It is sad that such people find so much space in the media…

The course of this pandemic has been accompanied by an incredible amount of bizarre false news, to which unfortunately a considerable part of the population willingly listens. Every so often some guaranteed report flies in about the artificial origin of the new coronavirus, with Bill Gates, George Soros or the Chinese communists having a hand in it, about its connection with the 5G network, about guaranteed cures for the disease, or, conversely, about there being no such virus at all and the whole thing being merely a huge conspiracy of pharmaceutical companies, venal scientists and behind-the-scenes satanists bent on subjugating humanity.

I think, though, that these fakes are not the main cause of the hostile attitude of a large part (though probably still not the majority) of our society. I think the main source is an all too widespread personal philosophy of strident, selfish individualism. I know several highly educated people of this type well, who believe that we overemphasise the right to life at the expense of freedom — and that it is therefore all right to reject restrictions on freedom imposed by the state (on gatherings, on masks), even at the cost of the deaths of some of us. These fanatics of unlimited freedom argued in exactly the same way years ago over measures restricting smoking, or in discussions about tightening traffic rules (seat belts), or about introducing compulsory vaccination.

Some of these people barely conceal the fact that they would find it acceptable for us to take no anti-epidemic measures at all, or only minimal ones, and to accept that 5–10% of those at-risk groups (that is, more than 100,000 people) would die. They probably realise that the selective protection of those at-risk groups that they propose is hardly feasible, and yet they refuse to admit that such an approach would bring the collapse of the health service (unless the situation were simply dealt with by not admitting covid patients to hospitals at all and letting them die at home).

The present situation clearly reveals not only the questionable moral qualities of a considerable part of the population (which were, after all, also evident in attitudes to refugees) but also defects in fundamentally important functions of the state and its organs — the culpable failure before the onset of the autumn and New Year waves, the inaction of the police in cases of massive and downright demonstrative breaches of basic anti-epidemic measures. This weakness of the state in asserting and enforcing the measures it has imposed even raises fears of a kind of anarchisation of society. Unfortunately, this is greatly aggravated by the utterly irresponsible behaviour of an opposition that rejects the government's requests to extend the state of emergency.

On the other hand, it is admirable how strong and robust our health service is, what reserves it has and how devoted its staff are. It is commendable how generously the state is providing financial help to most companies and individuals affected by the impact of anti-epidemic measures.

Does "every cloud has a silver lining" apply here too?

The current covid crisis does have several positive aspects.

1. First of all, it has given a powerful impulse to thoroughly investigating hitherto unknown aspects of respiratory diseases. Surprisingly, it has emerged that we actually know very little about the mechanisms of damage to the respiratory tract, both directly by the virus and indirectly through inappropriately chosen weapons of the immune system. The epidemic has also underlined the need to develop new antiviral drugs (it must be admitted that of the promising ones so far, almost none has proved itself). We still know very little about the causes of chronic cardiac, vascular and neurological complications of covid-19, or about the reasons for the surprising heterogeneity of the disease's manifestations (asymptomatic versus severe or even fatal). Nor is there agreement among specialists on whether vaccinated people can continue to be asymptomatic spreaders of the virus, or even on the mechanism by which, and the extent to which, a vaccine administered into muscle actually protects against mucosal infection itself.
2. There has been not only incredibly rapid development of vaccines, but also perhaps still more remarkable development of fundamentally new diagnostic tools for the rapid and cheap detection of infected people.
3. This epidemic has shown us what citizens of some Asian countries have long known — namely, that face masks and especially respirators are an excellent means against epidemics of respiratory disease. I hope we will follow the Asians' example and thereby reduce the intensity of future seasonal influenza epidemics, which routinely claim around a thousand lives a year.
4. The epidemic has significantly accelerated the use of online forms of communication and teaching (especially for university students), has shown the advantages of working from home and of shopping online. It has become clear how much more efficient various conferences and meetings held online can be compared with those held in person, often in distant locations. If only this experience would at last lead to significant progress in digitalising other services of authorities and institutions.
5. It has become clear how important a strong and capable state is — one that is, among other things, able (and above all willing) to enforce compliance with the necessary anti-epidemic measures effectively. In connection with dealing with the current exceptional situation, fears of "unsustainable indebtedness" of the state should be rejected. The Czech Republic is still one of the least indebted states in the EU and the cost of servicing the debt (paying interest) is very low even after the present unprecedented increase in the national debt.

Lessons for the future

1. It is absolutely essential to improve the global system for monitoring potential newly emerging epidemics so that it is robust against bureaucratic errors at national level. In responding to potential danger it is better to exaggerate a little than to hesitate, as happened in most Western states in the spring of 2020. Such a system is as important for the future of humanity as, say, a system for the detailed mapping of potentially dangerous asteroids.
2. There can be no saving on investment in basic and applied research into antivirals and drugs that regulate the proper functioning of the immune system responding to infection; it has been confirmed that, as with a number of other diseases, severe cases can be caused by an excessive or poorly regulated immune response. Useful impulses may come from studying the details of how the immune system of bats works, in which viral infections do not cause similar problems because their immune system opts for a strategy of tolerance. It would be highly desirable to develop systematically drugs that work against a broader spectrum of respiratory diseases caused by different pathogens but with similar manifestations and mechanisms of lung damage. At our national level it would be very important to build a high-quality specialised academic virology institute, which the Academy of Sciences has been proposing for several months.
3. In future we cannot rely on profit-oriented pharmaceutical companies alone; public funds at European, and probably also national, level need to be invested in building an industrial base for producing vaccines and certain critically important drugs on a non-profit basis. It is paradoxical that if someone in academia discovers even a potentially fundamentally important drug and does not patent it sufficiently, it will remain of no interest whatsoever to pharmaceutical companies. Where the public and commercial sectors cooperate, the corresponding contracts should be entirely transparent, given the previous massive public investment. It is not acceptable for states to bear the financial risk of development while the profit belongs to a company and is its trade secret.
4. It is essential to keep a clear epidemic plan constantly at the ready and to know how to use it as well as the Asians demonstrated to us during the present pandemic.
5. The Ministry of Health and the public health service need to be reformed so that the present tragic problems cannot recur. The government must have effective legislative instruments at its disposal for managing exceptional situations, and the scope for harmful, short-sightedly politically motivated interventions by legislators must be limited.
6. We must give maximum support to, or rather require, the use of face masks and respirators immediately from the start of any future epidemics of respiratory disease.
7. Probably the most important task is to educate the population so that it understands the necessity of anti-epidemic measures and does not fall for various false pseudo-information. In present conditions of unrestricted internet spread of every kind of catchy nonsense, however, that is an almost impossible task. And there is certainly no hope of soon overcoming the influence of that philosophy of "absolute freedom" that takes no account of one's fellow human beings…

Václav Hořejší

Prof. RNDr. Václav Hořejší, CSc. is the most cited Czech immunologist and the discoverer of new molecules important for the activation and regulation of the effector functions of white blood cells, specifically T-lymphocytes. He is among the first immunologists to formulate the hypothesis of so-called membrane lipid rafts, which significantly influenced research into the function of membrane structures and molecules in cell activation. He works at the Institute of Molecular Genetics of the Czech Academy of Sciences.