Arthur J Ammann MD
Founder Global Strategies. Clinical Professor Pediatrics
Global Health Sciences Affiliate Faculty Member
University of California San Francisco Medical Cente
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Preface

It might seem strange to post a series of imaginary conversations with plague viruses on an ethics blog site, but the COVID-19 pandemic has uncovered issues that are central to how we value one another — fundamental issues of justice and equity.

Certainly, viruses themselves do not make moral judgments but the suffering and pain that they elicit force us to examine how we, as individuals and a society, react to catastrophes. The plagues that are elicit may indeed be an allegory of human destiny.

A focus on ethical issues that occur during times of plague is not new. Albert Camus in his novel, The Plague , utilized the black plague to cast individuals in various situations expressing the tension between good and evil, forgiveness and blame, action and inaction, hope and hopelessness. After his book was published many believed that it was an allegory of the German occupation of France warning against ignoring the rise of power and the consequences of indifference to humanity.

I begin this series of interviews with a question. Are the activities of these viruses random, or do viruses have the capability of planning their destructive behaviors to match our human weaknesses? After reading what they have to say, can we gain insight into what might be next for us, even as in this moment we are unable to control the newest of the pandemics? Read what follows carefully and determine whether the truth shall make us free or warn us of coming plagues that will enslave us all. Reflect on whether the tragedies precipitated by these plagues might be a means to force us to examine when and how we may have compromised our moral principles.

This series of conversations begins with the 1967 influenza virus (H2N2) pandemic. In contrast to the current COVID-19 epidemic it ended with 70,000 deaths compared to the current 550,000 deaths from COVID-19. Its containment was attributed to the rapid identification of the virus, a robust public health response and the production and distribution of 50 million doses of a vaccine within a four-month period. What accounts for the difference between the 1957 influenza virus pandemic and the current COVID-19 pandemic? Will the devastation caused by new pandemics viruses continue to escalate?

Part Two: A Conversation With COVID-19

Prologue

Dr. Ammann. No One Is Listening.
Montage: Jiří Cernicky, Schizophrenia. (1998)
Edvard Munch, Maiden and Death. (1894).
Edvard Munch, The Scream. (1893)
Edvard Munch, The Sun. (1912)
Out of the Void, Pacific Ocean
Liquidambar styraciflua (seed pods)

The second virus with whom I had a conversation was COVID-19. Her full name is SARS-CoV-2. She comes from the slightly less prominent family of Orthocoronavirinae. She prefers to go by her nickname of COVID-19. It was kind of her to accept an invitation to tell her story during a time when she is quite busy attacking and being attacked. Although H2N2 and COVID-19 come from different families they have some traits in common. They are both patient and don’t mind remaining undetected for decades while they refine their techniques for creating a pandemic. When they attack they move quickly and are quite vicious. COVID-19 is called a novel virus which gives her a special advantage. She will tell you how important this is because, as a novel virus, there is no pre-existing immunity in humans to slow her down. It’s kind of a one-upmanship among the families of viruses. One of the reasons COVID-19 is so eager to tell her story is that she is getting quite annoyed and angry at all of the mischaracterizations and misinformation that is being told about her and wants an opportunity to set the record straight. A warning. My conversation with COVID-19 was more provocative than with H2N2. I was surprised at how much she knew about us humans and how she used it to launch her very own pandemic.

What the COVID-19 Pandemic Virus Had to Say

Thank you for inviting me to join in the conversations. I have a few introductory comments to make. First, I belong to a family of viruses that live in bats, dogs, cats and even camels. Unlike humans, we welcome diversity in our hosts as well as ourselves and work together to ensure our success. I can’t imagine fighting against ourselves. I get my best mutations by living in bats who are very cooperative and never get sick while I am working in them. One characteristic of our family is that we are usually pretty low key and haven’t caused any major pandemics of significance in quite a while. But following my last mutation, and it was a major one, I had the feeling that this was it. Time to make my appearance!

I used the new version of myself with a very significant mutation to recombine with a new version of another virus that had also infected my host. You have already heard a little bit about what recombination means and how H2N2 is considering it as a possibility for his inevitable return. I won’t identify the other virus involved in my recombination but together, with our newfound power, we were ready to initiate a pandemic— so I went for it. I left my host in my new recombinant form and infected a human. I was now what you call a novel virus and a much more potent one because humans had no preexisting immunity to me. This was important. Other influenza viruses cause what I would call small epidemics and not pandemics. That’s because humans anticipate their arrival every year and can predict who might be the villain in the next epidemic. Then they jumpstart vaccine production. That keeps things in check, or at least that’s what humans believe. They seem to forget that my family can mutate around that predictability and create novel offspring. I always smile when I see how cocky humans are in overestimating their abilities and underestimating our power. Watch what I can do when they announce that they have a vaccine to keep me in check. It will slow me down temporarily but I will mutate around it and they will need to develop another vaccine.

It’s important for everyone to understand that my leap from my host into humans was not a random decision. I had to wait for just the right mutation and also the right human to carry me to a distant location. So did H2N2, and it has been interesting listening to H2N2’s explanation of why he chose 1957 to jump into humans and spread himself throughout the world. A lot of thought went into his decision. But if you allow me to be critical, I think the major reason his damage was limited was that he jumped the gun too soon, so to speak. He came close to having all the mutations he needed to cause as many infections and deaths as I am doing right now, but he just didn’t wait until all of the right genes were in place to make it more difficult to produce a vaccine. Perhaps too, if he had just waited another five or six decades, not very long for us viruses, we could have created a “one-two” punch. Keep tuned in about this. It may happen yet.

Nevertheless, I actually learned a lot from H2N2 about the importance of amplifying factors and how I could take advantage of them to cause faster infections, travel farther, and cause more deaths. Speed of transmission is really important because you need to get a pandemic going before humans have an organized chance to react. So, I waited six decades since the last major influenza pandemic until the US and the world population tripled. That gave me hundreds of millions more potential hosts to carry me around the world to create epicenters of infection, especially among poor and disadvantaged individuals. My most attractive hosts were people who were highly susceptible to being invaded by me. Many of them lived in prime locations like New York City with densely populated neighborhoods, inadequate health facilities and, one of my favorite places to attack, overcrowded nursing homes. Most everything that is that big is so dysfunctional that they won’t even acknowledge that I’m there until I’ve gotten a good foothold.

Transport ship. World War I

Regarding crowding, I learned something really important from the 1918 Spanish flu as well. The Spanish flu pointed out that crowding and human movement got him around the US, Europe, Central America, South America, and Africa, firmly establishing his pandemic.  He expanded his reach by hitching rides with massive troop movements in World War I, and just went crazy with excitement when all those soldiers were transported in jam packed troopships and trains. Tragic enough that they were going to risk their lives in war, let alone getting infected with the Spanish flu. Talk about germ warfare. The Spanish flu turned germ warfare against everyone.

I also learned from the Spanish flu that some things just don’t change even if a whole century has passed. The Spanish flu got help in spreading in the US from a well-publicized and highly political Liberty Loan Parade of 200,000 humans to promote World War 1 government bonds. It was considered unpatriotic to cancel the parade. I bet this sounds familiar to some of you humans today as you listen to certain politicians declare that nothing is going to stop their gatherings. My own assessment of the thought process is that I am glad we viruses have so many fewer genes than humans. Somehow during evolution humans got the narcissism gene and we viruses didn’t. We would never hold any kind of rally that would endanger our own lives.

So, the Spanish flu recommended that I wait for a more effective and rapid form of transportation to spread myself globally and search out areas of high human density. I decided to wait until 2019 when there were lots of jet planes crowded with people traveling around the world. I heard that last year there were 4 billion people traveling in airplanes. There were no jet airplanes for Spanish flu to take advantage of, and when H2N2 made his attempt in 1957 to create a pandemic there were just a few jets flying to and from Europe. I also learned that when humans get sick, even with what seems to be the flu, they don’t cancel their airline reservations. They just go and make believe they are perfectly well. That was a way for me to kind of sneak aboard a jet plane. I also briefly experimented with other ways of transporting myself, like cruise ships, but they were slow and it was too easy to quarantine all of my infected hosts to prevent me from spreading.

Grand Princess, San Francisco, March 7, 2020

Let me tell you a little bit about my thinking and, by the way, we viruses do think. First, we place a high priority on helping one another because we trust each other. Humans seem to put their trust in politicians and dictators who say they are out to help everyone but they’re really extraordinarily self-centered. Also, we are not like humans with complicated brains that sometimes get confused about what’s right or wrong. We can stay focused probably because we’ve got a limited number of genes and don’t make things too confusing. Can you believe this? Most of us viruses have fewer than 20 genes and humans have 25,000. It is like David and Goliath. I was able to create the current global pandemic with only a handful of genes and humans, with 25,000 genes, can’t seem to stop me.

Before I go any further, I would like to talk about the kind of location that we need to start a pandemic. First, we need the right host, not just any old bird or animal, and we need to have decades to develop the best mutations to make certain that our genes are working properly. Next, we need close proximity of humans to birds and animals. That’s usually easy to identify whether it’s in a resource poor country or even in the United States. We sometimes forget that the Spanish flu originated in pigs in Kansas where military recruits acquired the virus and took it from Kansas all the way to Europe in World War I. Other locations just won’t work. We know from past experience that cows in England, sheep in New Zealand or penguins in Antarctica aren’t the right hosts. Besides, there are not a whole lot of people living in those regions either.

Once we have the confidence that everything is a go, we wait for the best human candidate to infect. Ideally, it needs to be a person who is living in a really crowded village with lots of other people who have common colds or lung problems from polluted air so no one will think that anything out of the ordinary is happening. Then we start our process of spreading. Anyone who’s ever visited a resource poor country knows about the crowds, how they press in on you to the point of suffocation, and how individuals move from city to city even when they are sick. Most resource poor countries don’t have adequate healthcare so they don’t go to see a doctor or go to the hospital until they are really sick. During that delay there is a peak opportunity for spreading viruses like myself especially to vulnerable people. It’s like what’s happening now in the US where telemedicine is forced on the elderly and the disadvantaged even when they can’t use it. By the time they get the medical attention they are so sick that they are, I believe the expression you use is, – at death’s door. It didn’t surprise me that that I was able to cause the highest death rate among the elderly.

Another strategy that I used, which may seem odd, was to initially remain rather inconspicuous, by limiting myself to just a few cities until there was a plane leaving directly to Rome, Italy. You’re probably thinking by now: why didn’t she go directly to a place like New York City? Well, I needed to hone my capabilities, create refinements, and be certain that I could rapidly infect a large number of humans before moving to a highly desirable city like New York. Going to New York prematurely, before I was certain of my potency, may have impaired my ability to quickly create the pandemic.

Once I got to Rome, I moved out into some of the rural areas that were still reasonably crowded. I took advantage of the culture of Italy — close contact, intimate greetings, and sharing food, all of which help me spread quickly. It didn’t take me long to realize how effective I had become. I could use Rome as a hub for getting to other European cities and eventually to my most desired destination — New York City. Next, I found an unsuspecting, sweet, and affectionate elderly woman, who had saved up for a whole year to go to Brooklyn, New York to visit relatives. I parked myself inside her respiratory track and established a really high-quality infection that could spread through the cabin of the airplane when she coughed. For good measure, I infected at least a dozen more people on the plane, one of those new jumbo jets with more than 400 people board, a déjà vu of those crowded World War I troopships and the Spanish flu.

Selecting New York City was a no-brainer. I identified a city that was densely populated, had multiple types of public transportation with wedged in passengers, and crowds of people everywhere — stores, public events, entertainment spots, and even on the sidewalks. I got a real boost from the thousands of people who jammed into the New York subway system every day. I infected just a few key humans initially, which was all that was needed to take advantage of the wind currents created by the trains as they hurtled through the underground tunnels. It was an exhilarating experience to be distributed through those tunnels so effortlessly and land on unsuspecting individuals waiting on the train platform. It was a faster way of spreading myself than by just one person coughing on another person.

New York City had another fairly neat way of allowing me to spread myself. Those of you who have been to the city know that it’s a vertical city with millions of people using elevators every day to get to their offices in the skyscrapers. There are hundreds of thousands of people who live in high-rise apartment buildings that need to use elevators to get to the floor where they live. I love elevators for spreading myself. I cozy up to 10 to 20 candidates packed into a small space with the elevator whizzing up and down and with me swirling all around them until someone inhales me into their lungs.

Big cities like New York are really dysfunctional. Cities spend a lot of money pampering the top 10% of their residents but their support for education and health care for poor people is embarrassingly inadequate. Their politicians like to argue about almost everything and blame one another if something goes wrong. It’s hard to believe that some of the top city politicians and health officials actually denied that I had arrived in their city. By the time they reacted, I was firmly established and had already infected thousands of people. The newly infected humans unwittingly became part of my team and helped me spread myself beyond the city — to places like Connecticut, New Jersey, Florida, and even around the world as I hitched rides with infected humans traveling from the New York airports to more distant locations.

Nursing Homes 2020

Incidentally, New York has one of the highest populations of elderly people. That attracted me because I could easily infect them and cause a very high death rate. They lived under circumstances that were almost like being in prison and were getting the bare minimum of healthcare. Some of you may get angry at me for being so cavalier about targeting elderly people but if you think about it, I’m actually doing you an economic favor. You know as well as I do how much it costs your government to take care of the elderly through Medicare and Medicaid. Keeping some older people alive when they can’t even communicate and are going to die anyway doesn’t make much economic sense. Aren’t we doing you a favor if we reduce the population of elderly people? At least you can blame us without having to listen to the politicians come up with their lame excuses. Besides, maybe the money that is saved on healthcare could be used for something to benefit the younger population.

Here we are in July, 2020. Some humans may think that I am beginning to retreat now and others think that I’m going to come back with an even greater vengeance or perhaps combine forces with one of the more ordinary influenza viruses. I definitely want to wait until the usual human complacency sets in and scientists think that they’ve got all the answers. There are hints of that happening now. Then I’ll probably make my next move. Of course, I am not going to tell you when that will happen. I don’t want to reveal my secret intentions. I may use some of the things that I am learning now and return at a future date when you humans will have created even better conditions for me, like massive increases in the population of humans and equally large increases in the number of the poor and elderly.

You may wonder if there is any good at all that I, as a virus, or members of my family do? Not really. Some humans, especially scientists, may argue with my opinion and point to esoteric manipulations of different viruses to create new treatments and vaccines. As s for my opinion, I guess the only good that we viruses might be accused of accomplishing is limiting the world’s population growth and reducing the economic burden on the rich to have to take care of the poor, the weak, the elderly, and for that matter, anyone who is deemed to be a burden to society.

My future plans are not fully formulated. There are some variables that I have to work out such as the selection of my future animal hosts, whether I try recombination again, how many times I will need to mutate to outsmart the vaccine and make it ineffective, and where and when I might initiate the next pandemic. That’s all I am going to say right now except that I believe that my most recent mutations, if you don’t mind me boasting, will in all likelihood give me a superior advantage over anything you humans might invent. I have not been idle during the delays of responding to me. Political interference, public health delays and delays in developing a vaccine will provide me with the time I need to improve myself with new mutations and test them out in my favorite animal hosts.

I will let you in on something that you are probably reading about. I am impressed with how closely many of you follow all of the details of my activities, even down to the molecular level. Scientists have recently claimed to have identified one of my new mutations that allows me to spread more broadly and infect more people but not make them sick. Naturally, that’s not news to me. You humans should start thinking about what that might mean. I’ll get you started. Why would I ever weaken myself? Was my most recent mutation a mistake and will I gradually lose my ability to sustain the pandemic? Or, by infecting more people but not killing them will I have a vastly greater pool of humans to work on developing new mutations? Will I use the opportunity to develop a more virulent mutation? I’ll leave it to all of you to guess what I’m up to.

What about discovery of a vaccine to stop me and future novel viruses? Your modern science is amazing. However, the size and complexity of research studies today, compared to 1957 when 40 million doses of a successful vaccine were developed, tested, and administered in 4 months, has gotten so out of hand that it now takes a year or more to prove whether a vaccine will work. It’s another type of delay that allows me to get a stronger foothold into my current pandemic and perhaps, a head start in the next pandemic. Add to that arguments about intellectual property, who gets credit, an exponential growth of regulations, changes from nonprofits to for-profits and a change in medical research from what benefits the public to what benefits the individual and their institution. All these things will benefit me.

Do I have a contingency plan in case I have misjudged human capabilities? There is one that I have, and this is very preliminary: it’s evaluating my transmission from an entirely different animal host. I am certain that you humans have heard rumors of my living in dogs and cats. I realize that this may be just another one of those premature pieces of information. However, some scientists have already given you humans assurances that it’s nothing to worry about. That might be a comfort to cats and dogs and their owners, but I’m not giving up on the possibility. You humans better hope that you are not around if I start using dogs and cats to spread myself. Imagine the political and emotional battles between human rights and animal-rights groups when they talk about contact tracing and quarantines for pets and their owners. Well, this presentation may have ended but my story hasn’t. I really would like to go down in history as the virus that was unstoppable. I am working hard at it and I’m not giving up!

Arthur Ammann: Reflection on What COVID-19 Told Me

You have read an incredible story from COVID-19, one of three pandemic viruses that I had the privilege of speaking to.  I received some insight as to why and how COVID-19 created the global pandemic that continues to plague us. But during the conversation my mind sometimes drifted. Had I, like so many others, focused on the myriads of charts and graphs with their pronouncements of the number of new infections and deaths, without feeling the individual pain and suffering of those who were affected?

The legacy of COVID-19 is that her devastation will have gone far beyond the charted deaths of humans and uncovered the weaknesses of the world that we live in. Much of the success of COVID-19 was facilitated by factors that we humans consider to be advances for the good of mankind – globalization of the economy, urbanization, advances in science and technology, instantaneous communication, and rapid travel to every part of the world. But what is important, if not essential, for the survival of mankind, is how these advances are used and who will benefit from them. They are two edged swords that can benefit but also harm individuals. Viruses like COVID-19 are opportunistic and take advantage of our weaknesses — poverty, crowding, inadequate healthcare, inattention to public health, dehumanization, loss of compassion, self-importance, elitism, and political rather than moral control of decisions.

The COVID-19 pandemic taught me that if we wait too long to act before we recognize threats to humanity, viral or otherwise, we may succumb to a narcissistic philosophy of ethics that determines what we do by numbers alone and not by the value of the individual.

I am reminded of John Donne’s 1653 poem, No Man is An Island.

All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated… As therefore the bell that rings to a sermon, calls not upon the preacher only, but upon the congregation to come: so this bell calls us all: but how much more me, who am brought so near the door by this sickness… No man is an island, entire of itself… any man’s death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.

Selections from Divine Poems, Sermons, Devotions, and Prayers. John Donne, 1653