Year of COVID: Everything We Thought We Knew Was Wrong
Today marks one year since the day the World Health Organization declared that a new fast-spreading coronavirus had caused a pandemic.
“WHO has been assessing this outbreak around the clock, and we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction,” Director General Tedros Adhanom Ghebreyesus told reporters listening around the world.
“We have therefore made the assessment that COVID-19 can be characterized as a pandemic,” he said. “We have rung the alarm bell loud and clear.”
By that time, COVID-19 had been known to the world for little more than 2 months. In the U.S., we could see it coming, but hadn’t yet felt its full impact in our day-to-day lives.
Americans had watched in horror and trepidation as China and other Asian countries grappled with their outbreaks. By March 11, Wuhan, the city where the virus first emerged, was already more than halfway through its nearly 3-month lockdown.
Passengers quarantined aboard the Diamond Princess Cruise Ship had been released to return home.
The focus of the pandemic had shifted to Europe. Italy had just expanded a quarantine of its northern provinces to the entire country. Images and stories of overcrowded hospitals and patients dying for lack of medical equipment reached our TVs and phones.
A nursing home in Kirkland, WA, just outside of Seattle, was in the midst of a large COVID outbreak.
The U.S. had restricted travel from China, and would soon restrict travel from Europe.
The same day the WHO declared a pandemic, then-President Donald Trump addressed the nation from the Oval Office. “The virus will not have a chance against us,” he said, “No nation is more prepared or more resilient than the United States,” he said.
Today, of course, the U.S. leads the world in COVID-19 cases and deaths.
How did we get this so wrong?
Here’s a look at some of the many ways we underestimated the new coronavirus, and what those missteps have cost us.
March 2020: No Need to Panic. The Flu is Worse
March 2021: It’s Worse Than the Flu
The U.S. had a plan for responding to a pandemic. It was built around the flu.
Very few people in public health suspected a coronavirus could be this much of a threat for this long.
“I think we’ve been very focused on influenza. That’s with good reason because of historical precedent and that virus’s demonstrated ability to repeatedly cause pandemics and so, you know, I think we as a community did get surprised by it,” says Mark Heise, PhD, a professor of genetics at the University of North Carolina at Chapel Hill who studies host-virus interactions.
One of the things that makes influenza so tough to stop is that people begin to shed virus before they show symptoms (sound familiar?). When you don’t know you’re sick, it’s hard to stay away from other people.
In the past, diseases caused by coronaviruses like SARS and MERS, while severe, proved to be manageable. They could be controlled.
“What we saw with these other coronavirus infections, people are not really highly infectious until day 5 or 6 of their illness, and you can identify them, isolate them, and you could really shut down ongoing coronavirus transmission of either SARS or MERS,” says Michael Osterholm, PhD, director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota.
Early on, Osterholm says he realized this new coronavirus wasn’t sticking with that script.
“For me was one of those really humbling moments because I went from ‘My worst fear is a flu’ to feeling reassured it was a coronavirus to ‘Oh my, this is a really bad, different coronavirus’ and that was just a period of 25 days,” he said.
At the end of February, he published an Op-Ed in The New York Times calling the crisis a pandemic and warning that the virus was spreading through the air, a stance that was decidedly against the grain at the time.
“I think probably more than any other time in my career, the amount of blowback I got was really substantial,” he said.
March 2020: Masks Aren’t Necessary
March 2021: Consider Wearing Two
On March 9, Fox News reporter Eben Brown asked the CDC’s Nancy Messonnier, MD, about the panic that was starting to set in around the U.S. He said he’d recently seen someone wearing a face mask with canisters on the sides, and asked if she thought it might be a good idea to provide some sobriety to the American public on the risk posed by the new coronavirus.
Messonnier said that while masks were very important for health care workers, “We really do not think this is the time for Americans to be going out and getting masks.”
Other public health experts echoed those comments.
In a Capitol Hill briefing on March 11 2020, Lisa Maragakis, MD, senior director of infection prevention at the Johns Hopkins Health System told lawmakers, “This is another area where I think we need a lot of messaging to the general public because we do see a lot of images of people around the world wearing masks in public settings. The current guidance is that is not necessary and in fact may not even really add to protection,” she said.
In the midst of trying not to worsen severe supply shortages for health care workers, messaging about masks got muddled.
In fact, even at the time, there was good evidence to support the use of face masks. Most Asian countries were already using them.
Jeremy Howard, a research scientist at the University of San Francisco, and a team of volunteers, worked furiously to round it all up to try to convince public health officials and a wary public that masks were important. .
Looking back, Maragakis says, “I think this whole process has been humbling, you know for everyone.”
Maragakis says the pandemic response was bound to be messy. We were just learning about a new virus and everyone was trying hard to figure out how to stop it. What made this even more painful, she says was that people were following every twist and turn so closely.
“In science and medicine, we are used to the kind of ebb and flow of scientific information that you know, it’s not always linear,” she says, “You sort of find your way by triangulating amongst the different pieces of evidence,” she says.
“The whole public was faced with following along with science in a way that you know, I don’t think we usually get that level of scrutiny or attention that everyone is seeing blow-by-blow as scientific knowledge is accumulated in real time,” she says.
Still, Osterholm says mixed messages may have cost the U.S. in terms of public support.
“I think it is a really unfortunate situation because we burned a lot of bridges in terms of people wanting to follow or support public health measures,” Osterholm, says.
March 2020: Asymptomatic Spread is Rare
March 2021: 40% of New Cases Come From People Without Symptoms
The debate over asymptomatic spread boiled over in June, after Maria Van Kerkhove, PhD, head of WHO’s emerging diseases and zoonosis unit, told reporters, “From the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual. It’s very rare.”
The next day, she clarified that what she meant by asymptomatic was very narrow. She was talking about a person with a COVID-19 infection who never develops symptoms. She said transmission of the virus could be more common among people who are pre-symptomatic, meaning they will eventually develop symptoms, but haven’t yet.
In fact, she was hewing to published WHO guidance.
In a Feb. 1, 2020 situation report, WHO said, “Asymptomatic infection may be rare, and transmission from an asymptomatic person is very rare with other coronaviruses, as we have seen with Middle East Respiratory Syndrome Coronavirus. Thus transmission from asymptomatic cases is likely not a major driver of transmission.”
Evidence from outbreaks on cruise ships, homeless shelters, and church choirs, suggested otherwise.
A review published in September 2020 in the Annals of Internal Medicine rounded all this up nicely, estimating that 40 to 45% of coronavirus infections may come from people who aren’t showing any symptoms.
“I certainly wouldn’t have predicted asymptomatic transmission,” Heise says. He says this may be a case of people expecting this virus to be just like its older viral sibling. “With SARS-1, the people who transmitted were generally symptomatic.”
“We still have a relatively poor understanding of how SARS does a lot of the things that it does, from the non-respiratory symptoms that we see in inflammatory diseases, to effects on the heart, to neurologic outcomes,” Heise says.
“I think it’s important to remember, even though it seems like forever for all of us, we’re only a year into this outbreak. And so it’s going to take us a while to sort through the mechanisms and what’s unique about this virus,” he says “It has lots of secrets we haven’t worked out yet.”