World War C

by Sanjay Gupta

  Speaking of booster shots, if needed, I won’t hesitate to get one to keep my COVID immunity up to speed with the globe-trotting variants. COVID will continue to chase us, but we can chase life with science on our side.

  CHAPTER 9 F: Fight for the Future of Us

  Your Health Depends on Everyone Else’s Around the World

  Over the past twenty years, I have covered nearly every outbreak, epidemic, and pandemic in the world. When SARS erupted in 2003, I was in Iraq embedded with the US Marine medical unit known as the Devil Docs. Even during a war, the story of what was happening in China at that time broke through and frightened people. Sitting outside our tents with gunfire in the distance, I remember the Marines asking me how concerned they should be about the virus. As you know by now, SARS ended up being relatively rare, with fewer than ten thousand cases diagnosed in the entire world. Many may forget, however, that the case fatality rate was about 10 percent, which means for every 100 people who contracted the virus, 10 died from the resulting disease (the case fatality rate is the number of confirmed deaths divided by the number of confirmed cases). It is hard to conceive what impact COVID-19 would’ve had if it was similarly deadly.I

  Two years after the SARS outbreak, I was in Thailand, Laos, and Indonesia covering H5N1, the avian flu. Details were sparse when we arrived during the 2005 holidays and stayed over the new year into 2006. There were just a few dozen cases, but the fatality rate was already well above 40 percent and would continue to climb. Back then, a frequent guest during my live reporting was Dr. Anthony Fauci. “This is the one that keeps me up at night,” he had told me back then. A highly deadly flu that was also very contagious. Fortuitously, neither SARS nor H5N1 spread easily around the world.

  Three years after that, in 2009, another flu virus started to spread from a small region of central Mexico. It was called H1N1 or swine flu. (The term swine flu is a misnomer; this strain is made up of several different components, including swine but also avian parts.) Five-year-old Edgar Hernandez was believed to be patient zero, first identified in a story I did for CNN as we traveled through Mexico with a group of disease detectives. Unlike SARS and H5N1, the swine flu was very contagious, and 60 million people in the United States were believed to have been infected between April 2009 and April 2010. The case fatality rate, though, was much lower: 0.02 percent. There were more than 270,000 hospitalizations and around 12,000 people died of that flu. Although the disease wasn’t that deadly, I can tell you from personal experience, it was awful.

  Throughout all of my coverage and travels to hot zones, I stayed disease free until September 2009. I was once again in the Middle East, this time covering the conflict in Afghanistan. It started as a cough for me. That wasn’t unusual: We were in the desert, and dust was constantly being kicked up into the air. But my cough was different. It hurt—a stinging pain that made me wince and immediately hope that I didn’t have to cough again anytime soon. I thought I might have a fever, but of course, I was in the middle of covering a war in Afghanistan, and the conditions were, well, hot. So maybe it was that. Problem was, the next day I was feeling worse. I woke up in my dusty desert tent and tried to step out of my sleeping bag. Two steps later, I hit the deck. My body simply could not hold me up. I was light-headed and freezing cold, even though it was already over 100 degrees outside at that early hour of the morning.

  I was nauseated, and my entire body ached. I tried to explain away my symptoms with lots of different excuses. You don’t sleep much while covering a war. My bulletproof jacket didn’t fit perfectly and was very heavy. Maybe I had what the Marines referred to as the Kandahar Krud. It turned out to be none of those things. I remember looking over at my cameraman, Scottie McWhinnie. He looked absolutely awful too. He was wearing a scarf on his head and it was drenched in sweat. He was coughing so loudly and frequently that I was starting to worry about him—and about myself. We each had it, whatever “it” was. I made a command decision: As a physician reporter in a war zone, I was going to get us medical care.1 That prompted a visit to a battlefield hospital, not as reporters this time but as patients. There wasn’t much they could do for us, except confirm that it was in fact H1N1 and pump us full of IV fluids.

  This was the sickest I have ever been and, in the days it took me to recover, I lost fourteen pounds. My wife looked at me horrified when I finally arrived home. It took a lot of convincing a few years later when I told her I was thinking about flying to another hot zone—this time to cover the hemorrhagic fever Ebola, which ended up being one of the most profound experiences of all.

  Spring 2014

  It took only moments to feel the impact of what was happening. My crew and I had just landed in Conakry, the capital of Guinea in West Africa. In the fields right outside the airport, a young woman was in tears. She started to wail and shout in Susu, one of the forty languages spoken in this tiny country of 12 million people that is also one of the poorest places in the world. The gathered crowd became silent and listened intently. The young man sitting next to me quietly translated, although I already had my suspicions. He told me the woman’s husband had died of Ebola, and then he quickly ushered us away.

  Ebola rarely made it out of the remote forested areas of Africa, but there was growing concern about it reaching populous areas, including where I’d just touched down, an international airport. Guinea’s foreign minister initially said that the West African country had brought the spread of the deadly Ebola virus under control after more than a hundred people had died. When I asked doctors on the ground about the risk of Ebola breaching the gates of the country and making a global escape, however, they had split opinions. Several told me the concern was real but unlikely. Most patients with Ebola came from small villages in the forest and were unlikely to fly on international trips, they told me. Furthermore, they didn’t think Ebola would spread widely in a Western country like the United States; our medical expertise and our culture—not touching the dead—would prevent it. Others weren’t so sure, and no one wanted to test that theory.

  With Ebola, there is an incubation period of two to twenty-one days, the range of time it takes to develop symptoms after someone has been exposed. With an international airport close by, that means you could be on the other side of the world before you develop the headache, fever, fatigue, and joint pain that make up the early symptoms of an Ebola infection. The diarrhea, rash, and bleeding come later. Hiccups are a particularly grave sign with Ebola. It means your diaphragm, which allows you to breathe, is starting to get irritated.

  Like COVID, there is a lot we have learned about Ebola, and it scares us almost as much as what we don’t know. We do know that Ebola, a simple virus with a small genome, is a swift, effective, and bloody killer—the contagion of horror movies.2 The mortality rate is higher than 50 percent, and in some outbreaks, it reaches 90 percent. Ebola appears to kill in a clever way. Early on, it strategically disarms your immune system, allowing the virus to replicate unchecked until it invades organs throughout your body. It convinces your blood to clot in overdrive, but only inside your blood vessels. While those blood vessels choke up, the rest of your body starts to ooze because the clotting mechanisms are all busy. You start to hemorrhage on the outside of your body. Your nose and eyes bleed; you start to bruise, and there is no clotting when you puncture your skin. But it is the bleeding you don’t see, the bleeding on the inside, that causes even more catastrophic problems. Many patients die of shock within an average of ten days.

  Yet despite the real danger, Ebola is not easy to “catch.” To become infected, you generally need to spend extended time with someone who is gravely ill and come into contact with his or her infected body fluids. That’s why family members and health care workers are the most likely to get sick. With some infections, including COVID, you can shed and spread the virus long before you get ill. That’s not the case with Ebola. Only after you are sick and feverish do you become contagious. However, it only takes a minuscule amount to infect and kill. A microsco
pic droplet of blood or saliva on your bare hand could enter through a break in your skin. And whether you realize it or not, we all have breaks in our skin. After being on the ground for a few days, I realized it was only a matter of time before Ebola would breach the gates of Africa.

  A few months later, as the outbreaks continued to rage in West Africa, Ebola landed in the United States. The virus first arrived via US missionaries flown here for treatment over the summer. It was also unwittingly imported by a forty-two-year-old Liberian tourist named Thomas Eric Duncan, who flew from Liberia to Texas with the virus and later died in Dallas. Two nurses who treated Duncan contracted Ebola on American soil, and both recovered. We all heard about these cases in the media, and rallied for the infected. Overall, eleven people were successfully treated for Ebola in the United States during the 2014 epidemic that originated in West Africa.

  This is a crucial point, and brings us to our last lesson. None of the patients who contracted the virus in America died, and yet more than one in two perished in Africa. Although the virus doesn’t discriminate, your survival depends not only on the country but also the zip code of where you were infected. All of the survivors in the United States had one thing in common: They were rushed to two of the country’s four hospitals, including my own at Emory University, that had been preparing for years to treat a highly infectious disease such as Ebola.

  That wasn’t an option during the COVID pandemic and as a result we witnessed awful discrepancies in outcomes across the country. Ebola is probably never going to spread in the United States as it can elsewhere because it’s just not the kind of virus that can gain the upper hand in our system. But a germ like COVID? It demonstrated how quickly it could move, and how badly prepared we were to manage the damage equitably, both at home and as citizens of the world. COVID also showed how little we understand the public health adage I first heard in Africa: An outbreak anywhere in the world is an outbreak everywhere in the world. Remote corners of the world may as well be in our backyards. Until we fill the gaps and close the divides globally and nationally, a pathogen like COVID could be as horrific and devastating a menace as Ebola.

  This is why we each have an obligation to make sure we help prevent outbreaks in distant lands. In an ideal scenario, the most vulnerable to a disease would be vaccinated first, no matter where they live. Instead we find ourselves vaccinating a person every second in wealthy countries while some countries haven’t received any vaccines at all. As of spring 2021, the vast majority of all vaccines have gone to high-income countries (reflecting 16 percent of the world’s population) while less than 1 percent have gone to the low-income tier.3

  India’s Second Deadly Surge Is a Cautionary Tale

  On April 23, 2021, I was feeling more optimistic than I had in a long time. My wife and I even went out to dinner with a couple of friends at a local restaurant, dining outside. Admittedly, it was a bit socially awkward, given it was the first time we had done this in more than a year. But as we lowered our masks and saw smiling faces, it felt really good, almost normal. We gossiped about what was happening in the neighborhood, swapped some good quarantine stories, and even made plans to do it again soon. For the first time, the future didn’t feel blank to me, as it had for so long, stuck in my sensory-deprived basement.

  I woke up the next morning to shattering news: A beloved uncle had suddenly and very unexpectedly died of COVID in New Delhi, India. He had become ill the previous Monday, was hospitalized on Tuesday, and died Thursday. The cremation was scheduled the next day. It was so swift that it felt like a death from a traumatic accident as opposed to from an infectious disease. This particular uncle was a favorite among the dozens of our Gupta cousins. He was the natural storyteller, always wore a smile, and was also the most permissive of all the elders—sneaking us drinks at family weddings. He was a perfectly healthy man in his early seventies until COVID claimed him.

  It was also particularly shocking because after riding a long but mostly contained wave of COVID in 2020, India looked to be in great shape in early 2021. The second most populous country after China, India is home to one out of every six human beings on the planet. In the first week of March, its health minister declared that it was in the “endgame.” But by mid-March a devastating second surge took the country by surprise, and cases climbed sharply until they hit the world’s highest single-day count since the pandemic began—more than 400,000 new infections, beating a previous record set by the United States with 300,310 new cases on January 2. The case counts and deaths were likely massively underreported.

  Source: Johns Hopkins University CSSE COVID-19 Data4

  Hospitals ran out of space, oxygen and antivirals disappeared, and the descent into crisis led to massive cremation sites being created out of parking lots. Reasons for the surge included a vacuum of leadership in the central government and an exhausted public eager to let its guard down after an intense lockdown in the first wave that crushed their economy. Leaders did little to discourage public gatherings, allowing a massive weeks-long Hindu pilgrimage to proceed with millions of attendees traveling across numerous states. At the same time, political rallies attracted large unmasked crowds and became superspreader events. New, stickier, and more contagious variants were born that were more lethal, deepening the death toll. Experts’ warnings about a potential second wave had gone unheeded. The country, once a model for its pandemic response, suddenly found itself at the forefront of the news. People around the world watched, wondering what it all meant for them. There was some good news: The existing vaccines were still protective against the emerging variants in India, but only if you were lucky enough to get one.

  Source: Johns Hopkins University CSSE COVID-19 Data5

  India happens to be one of the largest producers of vaccines in the world, but it exported much of its supply before inoculating its own people. By the time the second surge took off and people needed medical help, it was too late to mitigate and contain the virus. Barely 3 percent of India’s population had been fully vaccinated, and only 9.2 percent of people had received at least one dose when the second wave hit.6 My uncle, who would have been in the first group of eligible people in the United States, had not yet had access to the vaccine.

  My parents, raised in India, were particularly disturbed by this. They had received the first shot of their vaccine at the end of December 2020. My mom, one of the most determined people I know, had found that her local county library had three hundred doses of the COVID vaccine available and would start immunizing at 9:00 a.m. on December 29. She grabbed my dad and camped out in front of the library starting at 1:30 a.m. It was as if she were waiting for tickets to a Grateful Dead concert! They were eventually given numbers 288 and 289 and happily sent me pictures of their vaccine cards later that morning. By May 10, my three girls had the vaccine authorized for them and were among the first very enthusiastic customers in their age group. We couldn’t help but wonder: If my uncle had been a resident in the United States, would he still be living today? And my dad wondered aloud what would have happened to him if he had never left India.

  Hope in a Hurry

  Pandemics unmask who we really are—our morals, our values, our ethics, our humanity. They test us in ways that nothing else can. But despite the losses and hardships we’ve all endured over the pandemic so far, there have been moments when the best of our humanity has come through. People I’ve talked to have shared beautiful stories of rekindling old friendships, connecting better with loved ones during lockdown, spending more time in the kitchen and garden, learning new skills and finding fresh hobbies, reaffirming their sense of purpose in work or perhaps seeking new purpose in a different job, feeling a greater awareness of culture and community, and overall being more conscious of the fragility of life. I encourage all of you to try to take this opportunity to reflect about what changes from the pandemic you might want to make permanent and which habits you are most eager to abandon.

  I am an eternal optimist and trust we will con
tinue to rise to whatever occasions await us in the future. More than one hundred years ago, the pandemic of 1918 killed nearly 200,000 Americans in October alone.7 The antimasking campaigns were relentless. The volume of people arrested for refusing to wear masks so overburdened the court system that public health authorities stopped making arrests. The case numbers started to climb again after Thanksgiving, partially blamed on Armistice Day celebrations for the end of World War I and relaxed restrictions over the holidays as people grew tired of pandemic life. But we all know that viruses don’t take a vacation. In December, news headlines said Santa Claus was “Down with the Flu” as schools closed and health officials ordered department stores to dispense with “Santa Claus programs.”8 By January, the country was fully engulfed in the pandemic’s third wave, and it would not subside until the summer of 1919.

  A lot has happened in the past century. Since the Great Influenza, we’ve gained the Internet and smartphones, extraordinary medical technology, and a greater understanding about diseases and ways to treat them. The COVID crisis finally propelled mRNA vaccines across the finish line, which will prove to be a powerful tool throughout many fields of medicine. But the pandemic also took us down to the studs of what life is about. As my wife tells me, “It’ll be a bad scar that still aches sometimes because we’ll always still feel bad about all the lives lost to this pandemic, but we’ll learn and move forward and still grow and develop in a way that helps us in the future.”