Not all nations acted on time. “History teaches us that men and nations behave wisely once they have exhausted all other alternatives.”. And their citizens have paid for it with too-high mortality and economic decline.
Science as a pretext of coronavirus crisis responsibilities exoneration
A few days ago in the Senate, the director of the Spanish Prime Minister’s Cabinet presented the 2019 National Security Report, which was approved on 4 March by the National Security Council and in which — radically modifying the approach previously established in the 2017 National Security Strategy — the risk of the pandemic was considered unlikely and “low impact” (1). A few days later, the philosopher Javier Gomá said, referring to the catastrophe experienced since the outbreak of COVID19, that “science has been used as a pretext for the exoneration of responsibilities”(2).
We have suffered a situation that was avoidable and as such, we need to take a rigorous look at the terms in which science and experts had expressed themselves prior to this event. The first thing that should be said is that we have experienced a disaster. According to the United Nations, a disaster can be defined as “a serious disruption of the functioning of a community or society involving widespread human, material, economic or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources”(3). The threshold that the International Monetary Fund considers for an economic disaster is a 0.5% loss in the GDP. In Spain, the official death toll varies between the 28,000 recognized by the Ministry of Health and the 48,000 reflected by the Spanish National Institute of Statistics, until this article was written (4). The GDP loss recognized for this year by the OECD is more than 10%. Although these figures technically define the disaster, its magnitude is better explained by the feeling of helplessness, grief and pain that we have all experienced, with overstretched health services and people dying in anonymity (read our article Widespread COVID-19 infection among Spanish healthcare professionals did not occur by chance).
The ecological balance
Human beings share planet Earth with animals and plants, but above all with viruses and bacteria. There is a certain balance of coexistence between all of us, which we call ecological balance. The gut of every human being contains thousands of microbial species and billions of organisms; there are more individual microbes in each human intestine than human beings on the face of the planet.
In order for an infectious disease to emerge in the human population, something has to change in the ecological balance, and these changes are the main factors contributing to the development of risks. Viruses and bacteria have produced devastating pandemics throughout history as a result of these imbalances. The plague that struck Europe in the mid-14th century killed more than a third of its inhabitants; in many populations, no one survived. The 1918 global influenza pandemic affected one-third of the world’s population and killed 50 million people, 2.8% of the total population.
Man’s action increasingly interferes with the ecological balance, increasing the likelihood that infectious diseases will arise. As a consequence, despite the great scientific and technological advances in the 21st century, humanity cannot feel safe in the face of this risk.
First serious warning at the dawn of the 21st century
During the more than forty years since the discovery of coronaviruses (HCoV-OC43 and HCoV-229E), these were considered only slightly harmful to human health. The rapid global spread of SARS-CoV in 2003 changed this paradigm dramatically.
The disease first appeared as a major outbreak of atypical pneumonia in Guangdong (China) in November 2002 and spread to Hong Kong, where a notable “superspreader” event took place on 21 February 2003, leading to major outbreaks in Canada, Vietnam and Singapore. Acute respiratory syndrome (SARS), until terminated in July 2003, recorded 8,422 cases and 916 deaths in 29 countries (5).
The relatively high case fatality rate, identification of superspreaders, the novelty of the disease, rate of its global spread and public uncertainty about the ability to contain it all helped to create widespread alarm. The possibility of repetition of similar events is accepted as highly likely, and it is assumed that any new virus that disrupts our life could be much more transmissible and lethal (6).
In October 2004, the World Health Organization (WHO) published the document “SARS Risk Assessment and Preparedness Framework”(7), which contains the plan to prevent similar future episodes. In it, the WHO “strongly recommends that all countries undertake a risk assessment as a basis for contingency plans […]”, and also details other recommendations directed at the national health authorities in all countries, such as “[e]stablishing an effective SARS response management process and the chain of command by assigning specific roles and responsibilities to key agencies” and “[d]etermining the most effective ways of providing human resources and logistics support for outbreak response”. It goes into even more detail, with a call “[to ensure] supplies of personal protective equipment, other essential equipment and pharmaceuticals, and logistics”.
Two years later, in 2006, the WHO again drew attention by publishing the book “SARS: how a global epidemic was stopped”(8), with the participation of 33 experts who analyzed everything related to this incident from different perspectives. Brian Doberstyn, author of the chapter What did we learn from SARS?, emphasized as the first lesson that “we were lucky this time”, since “certain characteristics of the SARS virus made containment possible. Infected people usually did not transmit the virus until several days after symptoms began and were more infectious only by the tenth day or so of illness when they develop severe symptoms. Therefore, the effective isolation of patients was enough to control the spread. If cases were infectious before symptoms appeared, or if the asymptomatic cases transmitted the virus, the disease would have been much more difficult, perhaps even impossible, to control.”
He also highlighted that the role that scientific advances played in containment was not relevant: “Sequencing the genetic code of the virus, for example, helped identify the origin and spread of the virus, but did not really help to control it. […] But laboratory tests were helpful in confirming SARS infections, especially in clinically atypical cases. Most important in controlling SARS were the 19th-century public health strategies of contact tracing, quarantine, and isolation.”
MERS: a new episode that reinforces the potential danger of coronaviruses
In 2012, a new version of coronavirus dubbed MERS (Middle East Respiratory Syndrome)9 was detected in Saudi Arabia. Initially, it had a mortality rate of 65%. It affected six countries in the Middle East, but cases were also recorded in France, Italy, Germany, Tunisia and the United Kingdom. The basic reproduction number R0 (the number of secondary cases each patient is expected to infect in a fully susceptible population) was very low (in the order of 0.6), preventing the level of a pandemic from being reached.
2012 Germany conducts a pandemic drill to prepare its defense mechanisms
Conducting drills is a tried-and-tested instrument in emergency preparedness. We are accustomed to the development of evacuation drills, rescue drills, military exercises, etc. Simulation allows us to evaluate work systems or processes with their operating instruments, procedures and templates, as well as to train or exercise decision-making and coordination.
The process of evaluating results should help identify critical areas of management and aspects that need to be strengthened.
The German government raised the question of how the state could develop preventive planning against this type of risk. Consequently, in 2012, it commissioned the Robert Koch Institute to develop a simulation, a sound risk analysis that would reveal the expected effects on the population, its livelihoods, public safety and order in Germany (10).
The risk analysis “Pandemic caused by Virus Modi-Sars” describes the global spread of a new pathogen originating from Asia: the hypothetical Modi-Sars virus. The scenario, the story that scientists traced eight years ago was based on their actual experience with several past epidemics (influenza, HIV, SARS-CoV, avian influenza H5N1). It is astonishingly close to current processes: the hypothetical pathogen “Modi-Sars”, transmitted from a wild animal to humans somewhere in Asia, turns out to be transferable from person to person. Since infected people do not get sick right away, but remain carriers of the virus, it takes time for the danger to be recognized. In the scenario, two infected people fly to Germany. One attends a trade fair, the other resumes his studies after a semester abroad. These two “index patients” spread the virus through their extensive social contacts. Infections rise with increasing speed. In the simulation, the virus spreads in Germany over a period of three years. After three years, a vaccine should be available. Three waves of infection occur during this time, affecting many millions of Germans and resulting in the deaths of more than seven million, as experts assume a very high mortality rate of 10%.
Different types of measures are implemented in the drill. The spread of the virus is slowed and limited by “anti-epidemic measures”, such as quarantine for persons in contact with infected persons and isolation for highly infectious patients. School closures and cancellations of important events, without which the course of the virus would be even more drastic, is also analyzed. The high number of treatments poses immense problems for both hospitals and medical staff, and many of those affected are treated at home or in emergency hospitals. The number of staff losses, above average due to the increased risk of infection, further aggravates the situation in the field of medicine. Bottlenecks arise for pharmaceuticals, medical devices, protective equipment and disinfectants. The industry can no longer fully meet the demand. In addition, the simulation reveals that the number of deaths among sick people in need of clinical care is increasing due to the overburdening of the health sector; additionally, the large number of infected persons exceeds the capacity of intensive care.
The knowledge acquired was incorporated into the National Pandemic Plan. Among other actions, “planning aids” for hospitals, the elderly and nursing homes were formulated, the “storage” of respiratory masks and other hygiene protection items was promoted, and management concepts “for rapid acquisition in the event of an emergency” were established.
It is important to note that all the information provided to the German parliament is public, enabling it to be analyzed by third-party countries. Among the conclusions that should be underlined, it is worth highlighting that the hypotheses used are very similar to the characteristics of the current pandemic, which proves that they were possible and probable conditions. It highlighted the importance of immediate action to limit the scope of the pandemic and revealed bottlenecks in healthcare. It allowed them to see the extent of not paralyzing the country’s overall activity because of its serious economic consequences.
The clarity of Dennis Carroll
In 2016, the Rockefeller Foundation mobilizes international civil society, brings together opinion leaders, experts in the field, researchers, representatives of international organizations, donors and foundations around the world reflecting on the obvious fact that the common thread of almost all identified pandemic threats is that they are viral. And this is a problem because the virus turns out to be an enemy that we do not understand very well. The viruses we “know” are just the tip of the iceberg. According to the most recent viral research data, there are an estimated 500,000 viral species still to be discovered in taxonomic groups that are capable of posing a threat to public health. Based on all these arguments, they launch a ten-year research project, The Global Virome Project, to develop a virus database. The warning of its president Dennis Carroll on the occasion of its launch is important: We live in an era where the long shadow of a catastrophic pandemic looms over our world, threatening to dramatically alter the lives we live. The possibility that a single lethal microbe could suddenly emerge and sweep through every home, every community without regard to national boundaries or social and economic standing is a shared fear across the globe. Global trends indicate that over the course of this century the rate of new disease threats emerge will continue to accelerate, as will the risk of a global pandemic. (11)
Spanish National Security Strategy
In Spain, under the Prime Minister’s Office, the National Security Strategy is drafted as a frame of reference for the National Security Policy, a State Policy that conceives security broadly at the service of the public and the State. The 2017 document12, valid for 5 years, warns that:
“This increase in risk situations associated with infectious diseases is the result of rapid global change that is altering human beings’ relationship with their environment […]. Spain—a country hosting more than 75 million tourists each year, with ports and airports among those with the most traffic in the world, with a climate increasingly favoring the spread of disease vectors, with an aging population and a polarized geopolitical situation—is not immune to threats and challenges associated with infectious diseases, whether natural or deliberate.” Consequently, “In addition to reducing the population’s vulnerability, it is also necessary to develop preparedness and response plans for health threats and challenges, both generic and specific, with a multi-sector approach to ensure proper coordination of all the administrations involved, both nationally and internationally”.
The GPMB warning
The Global Preparedness Monitoring Board (GPMB) is an organization established in May 2018 by the World Bank Group and the World Health Organization to help protect the world’s population from health emergencies.
In its first annual report in 2019, it draws international attention to the risk of a pandemic caused by a lethal and rapidly spreading respiratory pathogen. It states verbatim: “The world is not prepared for a fast-moving, virulent respiratory pathogen pandemic. The 1918 global influenza pandemic sickened one-third of the world population and killed as many as 50 million people – 2.8% of the total population. If a similar contagion occurred today with a population four times larger and travel times anywhere the world less than 36 hours, 50 – 80 million people could perish. In addition to tragic levels of mortality, such a pandemic could cause panic, destabilize national security and seriously impact the global economy and trade.” In addition, heads of government in all countries are directed to “routinely conduct multisectoral simulation exercises to establish and maintain effective preparedness.”(13)
Scientific consensus supports the idea that the emergence of a lethal pathogen with a high capacity for transmission is becoming more and more likely. Containment, especially in the initial stages, cannot come from the hand of medicine, since the characteristics of the pathogen and its behavior are unknown. The 2003 SARS pandemic ended without developing a vaccine. The available action measures are therefore contact tracing, quarantine and isolation. To minimize the extent of its spread, immediate action is required, in which every day counts.
Acting swiftly when it comes to starting up the machinery of a state requires advance preparation. Accordingly, both the WHO and other international organizations have requested the governments of different countries to perform risk assessment exercises as a basis for contingency plans. In Spain, moreover, the “National Security Strategy” document called for [the development of] preparedness and response plans. Simulation exercises are those that can detect and correct bottlenecks in healthcare and the logistics chain, and losses in the economy.
The exoneration of responsibilities for the coronavirus crisis is questioned
On 31 December 2019, the WHO office14 in China was informed of the existence of a new SARS-type pathogen; on 7 January, the Chinese authorities reported that the virus had been isolated in the laboratory.
But unofficial information about the outbreak began earlier: on 30 December, Dr. Li Wenliang, an ophthalmologist at Wuhan Central Hospital, alerted his colleagues to the advisability of using personal protective measures against the new pathogen, and the Chinese authorities forced him to recant publicly. Something smelled bad in authoritarian and censorious China, and the rest of the world should be vigilant. It was a matter of days.
Some countries reacted on time. Thailand15, Korea16 and Singapore17 implemented measures to assess travelers from Wuhan City on 3 January 2020; in Singapore, monitoring of pneumonia cases was intensified throughout the country. Japan (18) joined the control of travelers from Wuhan on 7 January, and on the 16th, implemented government-wide coordination mechanisms.
What was happening inside China was an enigma, but the spectacular images of the construction of a large field hospital and the export of cases did not tally with the official truth. On 26 January, cases of coronavirus had been detected in at least 10 countries, including France and the United States. The authorities of all nations should have been on alert and acted. Many nations acted on time and have been able to keep the pandemic under control.
There are also many in which their leaders have made good the words of Israel’s former foreign minister, Abba Eban: “History teaches us that men and nations behave wisely once they have exhausted all other alternatives.” 19. And their citizens have paid for it with too-high mortality and economic decline.
Bioethics Observatory – Institute of Life Sciences
Catholic University of Valencia
- EL PAÍS, 24 June 2020 El Gobierno anticipa dos años la revisión de la Estrategia de Seguridad Nacional por el coronavirus.
- Interview published in Spanish newspaper El Mundo on 28 June 2020 (“Los expertos han sido convocados de manera oportunista”)
- http://www.un-spider.org/es/riesgos-y- stres#:~:text=Tal%20como%20,sus%20propios%20recursos
- cf. El INE eleva a 48.000 las muertes en la pandemia con datos de todos los registros
- cf. SARS: The First Pandemic of the 21st Century
- Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. Stacey Knobler, Adel Mahmoud, Stanley Lemon, Alison Mack, Laura Sivitz, and Katherine Oberholtzer – 2004
- WHO SARS Risk Assessment and Preparedness Framework – October 2004
- SARS : how a global epidemic was stopped. World Health Organization – 2006
- Middle East Respiratory Syndrome Coronavirus: Epidemic Potential or a Storm in a Teacup? Alimuddin I Zumla, Ziad A Memish – 2014 – DOI: 10.1183/09031936.00227213
- Bericht zur Risikoanalyse im Bevölkerungsschutz 2012 Deutscher Bundestag 03. 01. 2013 (Deutscher Bundestag Unterrichtung)
- Guest Post | The Global Virome Project: The Beginning of the End of the Pandemic Era. Dennis Carroll 2016
- Estrategia de Seguridad Nacional 2017 A WORLD AT RISK Annual Report on Global Preparedness for Health Emergencies; Global Preparedness Monitoring Board September 2019
- WHO Novel Coronavirus (2019-nCoV) SITUATION REPORT – 1 21 JANUARY 2020
- WHO Novel Coronavirus – Thailand (ex-China) Disease outbreak news 14 January 2020 Novel Coronavirus – Republic of Korea (ex-China)
- WHO Novel Coronavirus – Republic of Korea (ex-China) Disease outbreak news 21 January 2020 Novel Coronavirus – Republic of Korea (ex-China)
- WHO Novel Coronavirus (2019-nCoV) SITUATION REPORT – 4 24 JANUARY 2020
- WHO Novel Coronavirus (2019-nCoV) SITUATION REPORT – 1 21 JANUARY 2020 http://quarantine.doh.gov.ph/who-event-information-site-for-ihr-national-focal-date-of-information-posted-21-january-2020/ Speech in London (16 December 1970);
- cf. The Times (17 December 1970)