May Day, May Day, the world has gone mad. Markets and money have gained overwhelming control of people and natural resources. Models have become weapons. The Capitol has been stormed. Myanmar’s military violently muzzles democracy, Navalny faces demise and journalists are jailed. There is nothing though that can compare to potential devastation posed by nuclear weapons, the greatest hazard to life on earth. The risk of absolute disaster comes closer. Pushed to midnight millions of years of evolution can unravel and human consciousness and culture could disintegrate. At that dreaded moment of a button pressed, the world will become a sinking submarine with one hour’s worth of oxygen at a depth that no olive branch can save.

We continue on the same yellow brick road to development, paying homage to the same model which makes humanity much poorer and pushes our planet further away from reasonable and fulfilling living. Poverty as defined by the economists has certainly fallen and fantastic things happen as a result of the great creative talent of human beings. The imbalance however is far too great. The existential threats are enormous.

When the World Health Organization determined that the COVID-19 outbreak was a pandemic (March 11th, 2020), globalization was in full swing, racism persisted, migrants were everywhere on the high seas, climate change was warming up the planet, declarations were crumbling and elections were on the agenda.

When I wrote my Ode to the Lockdown Monster, I thought that I had said my all on COVID: Endings, turnings-yearnings and new starts, beware of Cupid’s art, avoid sharp COVID’s darts. Love you’ll survive, COVID can bring agonizing demise, especially with my global health prescription and with my advice to Greece respectively:

Wear COVID out Quarantine, keep devils at bay

Wear COVID down lockdown, contagion give way

Trace, test, and test till we know, where the pest comes from, where do he go.

So once again, to Greece I say, do not unlock stay put,

Lay low, protect the loved ones that you know,

While in the words of a Nobel, noble poet

Just a little more and we shall see almond trees in blossom

Marbles shining in the sun.

Don’t frit away the glory that is there, coronavirus is not fair.

My brief perspective on COVID today and all COVID’s to come; COVID-19 did not create a new reality but greatly aggravated what already existed. Furthermore, economic systems rejuvenate better than people systems after a crisis. COVID has contributed to growing social dementia, global madness that we see and are living through today in a world poised between global impoverishment and inspirational innovation. Education should come first supported by classical philosophy.

Human behavior and systems integrity matter in the response to crisis and in determining the impact of any disaster. With insufficient public health and a lack of understanding of its value system the weakness of political leadership may be secondary but important and ASPHER must win it over.

How the world thinks and will think about lockdown and whether and how it controls a pandemic is a subject that should, and will, receive continual scrutiny. A proper and deeper understanding of pandemic containment policies and practical measures applied is important to third and fourth waves as well as for all future pandemics. With respect to COVID there are many knowns and far more unknowns. ASPHER has an essential role to play in making COVID’s known’s known and in searching for the unknown. ASPHER, as expressed both in the Skopje Declaration and the Athens ASPHER Accord has post-COVID, even a greater societal role.

Public health constitutes one fundamental element and practical ingredient for mankind’s hope for the future.

A half century Conversation, not-out

What the world needs now is a way to focus on problems too slow to be called a crisis and too risky to see it as anything else, the determination to ban nuclear weapons and the wisdom to prepare for crisis whether from pandemics or the effects on society from neural manipulation. The world’s population needs relief from inequality and worthwhile and more fulfilling living. In her talk the world is changing in the ongoing Social Summit, the European Commissioner Ursula Gertrud von der Leyen, a physician says we have to change. Without a significant increase in equality, a substantial social distancing from poverty and violence and a more deliberate reinforcement of public health the change that the Commissioner calls for, may remain a pipe dream. EU leaders are discussing and global cooperation to build a more resilient global health system and a strengthening of the World Health Organization (WHO). It will provide life-saving medical equipment to India and reaffirm solidarity with India and the global fight against the COVID pandemic. India needs oxygen and so does humanity. There were many powerful pushbacks from Big Business and conservatives who mistook protest for a lack of patriotism and told dissenters to find another country if they didn't love America.

Almost symbolically, the end-stage of a Chinese rocket reentered the earth’s sphere to come down in the Indian Ocean with most of it destroyed by the heat of friction when it re-entered the Earth's atmosphere.

Five decades ago I started a conversation with Surjit Singh Bhalla [1]  a Beatles fan at Princeton with interests in economics and politics. I was in Chicago working in biomedical engineering and neurophysiology. We were both interested in nonlinearity, mine in visual systems his in society. Our overlap was health systems.  His book on improving world equality – Imagine There’s No Country – was published in 2002 and he gave me a copy, which I cherish. That was two decades ago when SARS spread rapidly with a global death toll of 900 and a mortality rate of 10%. My loud clang of the Leper’s Bell was an appeal for more public health preparation and the use of the Utstein Template (WADEM) with the thought that disaster health management and public health are confluent rivers. The focal hazard then was SARS, today it is COVID.

Quite recently Surjit sent me a manuscript Lockdowns and Closures vs COVID –19: COVID Wins, asking me to read it while he read my article on Bhutan, keeping pace with its peripatetic Education Minister A lot of work went into Surjit’s analysis. His conclusion - there are more unknowns then knowns, or maybe, perhaps, we just don’t know. Thakur S. Powdyel offered, not to learn anything redemptive from so much pain and suffering  from COVID would be a tragic waste.

The scourge of COVID is presented by Surjit via a colossal and impressive gathering of data (Big Data). His study offers some counterintuitive conclusions and if we ignore boundary conditions a paradoxical and best outcome occurs; lockdown measures should be applied close to infinity or a long long time after COVID strikes. Going in the opposite direction; no COVID, no need for measures. This comes from a mental manipulation of the model and does’t make much sense, or does it. Models while useful to thinking and experimental design rarely predict significantly better than extrapolation. Without models and centers of excellence we would not have got so far.

We discussed the 1957-58 flu (H1N2) epidemic, which I came down with, and from which 25% of the U.S. population fell ill and excess mortality was registered. He tells me no futile efforts were made to quarantine individuals or groups and only a relatively small percentage of those infected required hospitalization. Jumping ahead, Surjit’s article shows that in only a handful of countries can lockdown be shown to have been effective. Surjit challenged me asking how can I lean towards the John Snow Memorandum. One answer given was that there was only one fully compliant lockdown and in China, which acted swiftly, forcefully and people followed measures. Another one labeled extreme “suppression” was triggered when a country reached 1.6 deaths per 100,000 residents but this threshold varied and official COVID-19 death and case counts may be far from the true picture. We recalled observations: one coming from Orwell and the west an Englishman’s arm is thicker than an Indian’s leg another coming from the east and Gandhi on India’s access to limited resources since the west has already exploited much of them. We talked about correlation and at what level it might become causal. We talked about cricket and noted that between a Yorker and a short pitched ball there are an infinite number of trajectories for the ball and how a ratio may fail to tell the truth if either numerator or denominator have been miscounted.

Our snapshots of COVID (Me, Surjit, Thakur) deviate from reality in different ways but we do not know by how much. Until we learn more, no country is out of the woods. Measures of normality may be light years away from reality. Surjit and I have different but somehow overlapping metaphors for COVID’s waves; an earthquake and its aftershocks for him, mine a forest fire, which can suddenly take a new direction as winds change or fire fighters (first responders) reduce the fury of one front. Wherever the front there is a sense of helplessness and fear, anger, grief.   We may agree upon that Lockdown, quarantine with its fuzzy logic works and has worked perhaps best in China and reasonably well so far in Greece. We may agree upon that Lockdown, quarantine with its fuzzy logic works and has worked perhaps best in China and reasonably well so far in Greece.

India is in the eye of the storm as a more infectious variant of COVID takes an iron hold with a greater power of transmission. It comes second after the USA with 20m cases. In just one week more than 2m cases occurred; on April 30th, 400,000 cases and 4,000 deaths were reported. The health sector is in collapse and lifesaving products are scarce and people have to fend for themselves. As oxygen runs out patients are gasping for air and literally grasping at life. Containment thinking is polarized between the elimination of hazard; removing it (no escape-no spread) or stopping the virus in its tracks, or suppression of its detrimental effects; achieved by mitigation and mainly by vaccines to confer herd immunity on the population. While science has worked at breakneck speed to produce a host of vaccines their distribution is difficult.

Not to forget that an earthquake in the Indian Ocean jolted the earth’s axis and triggered a large tsunami and a nuclear disaster in the poorly maintained Fukushima nuclear reactor. Radioactive fallout was enormous and added to that that Chernobyl emitted and there is no safe solution for the disposal of nuclear waste. Now with polar ice melting into the oceans a result of denied global warming, the earth’s mass is being redistributed and its axis perturbed towards a different dynamic equilibrium.

Surjit is now in the eye of the storm working on the epidemiology of T-cell immunity, a reappraisal of earlier viruses (the 1957-58 and 2009) and looking scientifically at India’s frightful plight with the second wave of COVID. He ponders the lead time to effective policy response: how much lead time did policy makers have and thinks about the 2021 COVID experience - across the world- and the fact that very few if any of the countries are going for a national lockdown – despite the fact that for 120 countries the maximum number of cases were higher in 2021 than in 2020 – and for more than 40 countries, the maximum per day caseload was more than twice that observed earlier. His focal interest is on India and the controversy about the “true” determinants of this second wave i.e. what were the effects of farmer protests and large election related gatherings on COVID diffusion. We touched upon the suddenness of the COVID spread with the new strain and  a threshold load viral packet quantum droplets to kick off COVID. Only human challenge experiments can provide an answer.

Our discussions brought out the work of Nobelist Amartya Sen; his reflections on the manmade Bengal famine during WWII, Ireland’s  potato famine and dengue fever in Greece and death by malnutrition during the occupation. Surjit says that the only real known is that vaccination works! Until herd immunity arrives and approximate full vaccination of the population (66 % = 1-1/R0) India will have a difficult road to reach herd immunity will continue to suffer. Already to its name-credit it has a voluminous information base and has collected several models that have wrongly predicted both where the pandemic has been and where it is going. There are different opinions from religion and the media and many other voices on where it came from, how it spread and where it strikes. Using 3 for RO for COVID and by comparison 10 for measles, its herd immunity requires a 90% inoculation rate.

Two reference points: a succinct appraisal of the Great Barrington Declaration by James Naismith who suggested that humility and willingness to consider alternatives are hallmarks of good science. Perhaps do no harm is the most appropriate advice and that we just don’t know is a most appropriate phase. The other are the words of Wislawa Szymborska (Nobelist in Literature); she said there are those who know well, what is going on and what it is all about but are pushed aside by politics to make way for those who know little and as little as nothing.

How do you measure suffering, the number of shed tears? Some may accept a world controlled by big government and support lockdowns; some may accept a business dominated society and accept big tobacco as a natural stakeholder in health; some may call for less government and accept a limited public health function. As I wrote in Sinking Submarine without Life Support PART I there is nothing though that can compare to potential devastation posed by nuclear weapons, to which I add, even a small-war will have devastating global repercussions and there is a  lack of adequate explanation for the health effects of radiation on the population. 

A subcontinent is reeling with India still in the eye of the storm and things will get worse before better. Given the shortage of vaccines, there will be a delay in the coming of herd immunity raising the likelihood of a third wave.

Forget the tearless statistics, pause for a few minutes to shed a tear for the physical and psychological suffering of all COVID victims and their families. Now let’s dry our eyes and spend the next hour pondering what ASPHER’s post-COVID agenda should look like. A knowledge of its trajectory………..

Burkle F.M. Jr. “Declining public health protections within autocratic regimes: impact on global public health security, infectious disease outbreaks, epidemics, and pandemics”. Prehosp Disaster Med. 2020;35(3):237–246.

Levett Jeffrey. Societal Dementia, Now and Then, Watched communities, side stepped expertise? 17 September 2019.

Levett Jeffrey. “Disastrous Events and Political Failures”. Prehosp Disaster Med. 2015;30(3):1 2.

Levett Jeffrey. Severe Acute Respiratory Syndrome (SARS): Loud Clang of the Leper’s Bell, 2003.

Lockdowns and Closures vs COVID –19: COVID Wins, Surjit S Bhalla; available at http://ssbhalla.org/wp-content/uploads/2020/10/Lockdowns-Closures-vs.-COVID19-Covid-Wins-Nov-4-1.pdf

With improved and faster testing, knowing better who was sick and who not long isolation could be reduced accordingly. But not in India.

Because individuals may be infectious before showing symptoms and a significant percentage of infected people never show any symptoms logic should be our guide to behavior and if we are in contact with a COVID-19 isolation at home is proscribed. The fully vaccinated, or those who are symptomless and have recovered within the last three months, which are insignificant number in India.

vaccines were produced fast because information was shared and governments  kicked in resources for pharmaceutical companies to work effectively.

Jeffrey Levett

International Gusi Peace Prize Laureate