Chances are good you have some dried beans on hand, and this is a great thing. Especially since one basic recipe works for so many kinds of beans from red beans to white cannellini to black turtle beans. I used that very recipe for a pot of red beans simmered in my electric pressure cooker.
First, I gave mine a soak, though its not strictly necessary. But I think soaking helps them cook more evenly, and soaking them in salted water speeds up cooking because the salt breaks down the bean skins. Anywhere from 4 to 12 hours does the trick, then you can drain and rinse them. But if time is an issue, dont soak.
To cook the beans, you can use a regular pot or a pressure cooker (electric or stovetop). Add the beans and cover them with water. If youre using a regular pot, add enough water to cover the beans by about 2 to 3 inches. If using a pressure cooker, add less water, more like 1 to 2 inches to cover the beans. Add a drizzle of oil and whatever aromatics you like.
To my pound of red beans, I added 6 peeled garlic cloves, a halved onion and a celery stalk. Herbs add depth; I had a bay leaf, but a few thyme or rosemary sprigs or a pinch of those herbs dried would have been just as good.
[For more on cooking beans, see Melissa Clarks guide.]
Now and, to me, this is the most important part add enough salt to make the cooking water taste like the sea. If using a regular pot, simmer the beans anywhere from 30 minutes to 3 hours, depending on what variety you used, how old they were and whether or not you soaked them. Check on them periodically, adding water if the level gets too low (as in, lower than the beans.) They will be tender but not mushy when done, and still look intact, without splitting or falling apart. For the pressure cooker, the timing is 5 to 50 minutes at high pressure. (Smaller beans will take 5 to 10 minutes, while larger beans, like chickpeas, may take up to 35 or 40 minutes.) Let the pressure release naturally.
If you want to add a Parmesan rind, or a hunk of smoked or cured meat, to the bean pot, you should it gives the beans great flavor. I had a chunk of last summers kielbasa in the freezer that needed a home, so I threw it into the pot.
Thats it. I always garnish with a drizzle of oil, a sprinkle of flaky salt and red-pepper flakes and any herbs I may have around, and call it a day. Grated or crumbled cheese and crisp bacon are two other options, as is a fried egg, which, after all, makes everything better. And as always, feel free to serve this with rice, polenta, or other grains, or some crusty bread, to round it out.
In this series, Melissa Clark will teach you how to cook with pantry staples. Check back Tuesday for another installment.
The next round of social distancing will be activated more rapidly, because officials and the public will be more prepared. It should also be shorter, because we can assume that most of the people who were initially infected are likely to be immune next time around. But it will still disrupt peoples lives and the economy. We will still have canceled conferences and sporting events. People will not frequent restaurants and will not travel. The service industry will be severely curtailed. And its going to happen again and again.
Maybe the best analogy is pumping a cars brakes on an icy road. Either doing nothing or slamming on the brakes leads to an accident. So we pump the brakes pushing on the brakes, then easing up, and then applying them again and after three or four times we slow down enough to stop.
When will the coronavirus be tamed like influenza, if not conquered like smallpox? A vaccine would need to be administered to an estimated 45 percent to 70 percent of the population at least 145 million people to stop the spread of the virus. If we are lucky, and an effective vaccine is quickly developed, this could happen by the fall of 2021.
It might even be sooner if researchers can come up with an effective treatment that, in addition to preventing deaths, reduces the infectiousness of each case. One antiviral drug, remdesivir, has shown promise in treating monkeys infected with a similar coronavirus, and is being studied in humans. Trials of other drugs will begin soon. Again, if we are lucky, these trials may identify one or more effective treatments in four to five months.
The alternative to this roller coaster would be even more drastic. It would require sustaining social distancing until there are no more cases whatsoever and then closing borders to all travelers no contact with the outside world for 18 months or more. While the United States and many other countries, like Denmark and Germany, have instituted travel bans, sealing the country off for over a year until a coronavirus vaccine is discovered seems implausible. But who knows. If the situation becomes dire enough, the previously impossible could become inevitable.
On a positive note, each time the virus resurges after social distancing is relaxed, it will do so more slowly. But the flattened curve we are all hoping for the one that is so critical to our health care infrastructure will not actually be flat. It is more likely to be a series of ascents and descents, with dampened oscillations. So all of us health care workers, policymakers and American citizens need to get ready for a bumpy ride.
Ezekiel J. Emanuel is the chairman of the department of medical ethics and health policy at the University of Pennsylvania, where Susan Ellenberg is a professor of biostatistics and Michael Levy is a professor of epidemiology.
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The US reported its first confirmed case of COVID-19 on January 21st. Eight weeks later, there still arent enough tests for the virus available for everyone who needs them. It is a failing, said Anthony Fauci, director of the National Institutes of Allergy and Infectious Diseases, at a House briefing last week. The system is not really geared to what we need right now.
People who are sick or have been in contact with sick people are struggling to get tested. Until last week, the number of tests that could be run per day in the United States was limited to around 7,000. Labs are struggling to get the supplies they need to meet the demand.
At the center of all of this chaos is a relatively straightforward type of test called a polymerase chain reaction, or PCR, thats been around for decades. To run it, a doctor swabs a patients nose or throat and sends the sample to a lab. The lab then looks for tiny snippets of the viruss genetic material. PCR analysis is complicated but reliable.
If the health system is working well, those tests should be good and help us manage this epidemic, says Catherine Klapperich, director of the Laboratory for Diagnostics and Global Healthcare Technologies at Boston University. Its frustrating that the testing we thought we could rely on didnt roll out the way we expected it to.
PCR works. But in an outbreak situation, even if its working well, its still too slow. Ideally, physicians would be able to run tests in an office or right at a patients bedside. The technology to test that way exists. But there hasnt been a large-scale investment made to commercialize it, so theres no clear pathway to get it up and running during an emergency.
Point of care testing is required for these outbreak situations. Were just not quite there yet as a scientific community, Klapperich says.
A week after the genetic sequence for the novel coronavirus first became available in January, German researchers had designed a PCR test that could detect the virus in a patient sample. That test became the basis for the World Health Organizations (WHO) test used in countries around the world, including South Korea, but which the Centers for Disease Control and Prevention (CDC) declined to use. PCR tests are, in theory, fairly simple to create: scientists pick snippets of the viruss gene and use a series of chemicals to look for that gene snippet in the sample. If they find the snippet, it means the patient has the virus.
PCR is the gold-standard testing platform for viruses because its highly sensitive, says Paul Yager, a professor in the department of bioengineering at the University of Washington it can detect even a tiny amount of virus in a patient sample and is less likely to incorrectly have a negative result.
In addition, its very well-known. It was first invented in the 1980s, and the patents on the systems needed to run it expired in 2005, leaving it cheap to do for any lab. If you know the sequence of the bug youre looking for and know what bodily fluid to look in, designing that test should be relatively straightforward, Klapperich says.
Its straightforward, but it can be slow. For weeks in the US, tests for the virus were being done by hand. Thats a time-consuming, technical process. Even though PCR tests are simple to create, theyre complicated to execute: a lab technician has to carefully mix a patient sample with tiny portions of chemicals in tiny tubes, and any bit of contamination can ruin the test. The samples also have to be repeatedly brought up to high heat and back down in a process called thermocycling, which is done on a specific machine. It takes a few hours to get results back.
Not every lab can do PCR. It requires a very clean lab, and its hard to troubleshoot, Klapperich says. I think of my hometown hospital theres no way theyre doing PCR in that hospital. Labs that can do PCR testing need special approval to run tests for patients, and getting permission can take months. Klapperich says her research lab in Boston could run around 80 tests per day if it had approval. The University of Washington virology lab, which has multiple machines and many skilled lab technicians, can do up to around 2,000.
The German test adopted and disseminated by the WHO scanned for three specific viral genes. Countries around the world were able to adopt and scale that test. South Korea, for example, quickly started testing around 10,000 people each day for the virus. So far, South Korea has tested around 250,000 people.
Instead of using the WHO protocol, the CDC decided to create its own test using three different genes from the German test. Thats not an entirely unusual decision the agency also created its own test during the Ebola outbreak in West Africa in 2015. But when some state labs tried to validate the test, it appeared to cause false positive results. The agency had to redesign and remanufacture test kits, which contributed to the delays in getting widespread testing up and running.
Normally, state public health labs and commercial labs would have been able to create their own PCR tests once it was clear the CDC test wasnt working. But because the country is under a public health state of emergency, any new test had to be approved for emergency use by the Food and Drug Administration (FDA). That slow process also contributed to delays in testing. On February 29th, the agency relaxed that rule, and commercial labs started COVID-19 testing.
Machines are available that can run PCR tests automatically, which also speeds the process. However, it took companies weeks to develop tests for those automated systems and for the Food and Drug Administration to approve them. The pharmaceutical and diagnostics company Roche, for example, didnt get approval for an automated test until March 13th.
Experts say the lag time and slow rollout was confusing. South Korea is working with the same technology as the US and was able to ramp up testing much more rapidly although, notably, it doesnt have the same regulatory barriers that the US does. But the US also has experience doing this well. During H1N1, that test came out quickly and was distributed, Klapperich says. Im not clear what went wrong here.
PCR tests are still the most reliable method of diagnosing a viral infection in a patient, even if the US is currently struggling to get up and running. But researchers around the globe are also accelerating work on other types of tests that can be done more quickly and closer to patients.
Speed is important during a pandemic, Yager says, because among other things it lets doctors figure out who has a virus quickly. What you dont want to do is bring someone with COVID-19 into a geriatric ward. You want to separate them. You want something that would give you a result in 10 to 20 minutes, he says.
Doctors regularly run flu tests in their offices and can have results back in around 15 minutes. Those types of tests dont look for influenza genes in a patient sample. Instead, they look for proteins on the surface of the virus. Those types of protein-based tests for the novel coronavirus are in development, Klapperich says. Its attractive because its a fast way of doing the test, she says.
However, those tests are far less sensitive than gene-based tests and are more likely to generate false negative results to say that the virus wasnt in a sample when it actually was. Proteins on the outside of viruses also change more frequently than their genes do, so the test could stop working. The tests are only as good as what you know about the protein, she says. Gene-based tests like PCR tend to be more accurate.
PCR is hard to bring to a patients bedside, though, because the thermocycling needed to run the test needs a lot of electricity. But theres another approach to gene-based testing, called isothermal amplification, which is simpler and can work at a fixed temperature. There are many ways to make isothermal methods work. Each one has its own drawback, and none is quite as convenient as PCR. But the drawbacks can be overcome because theyre smaller, simpler, and more lightweight, Yager says.
Yagers lab created a small isothermal system that could be used outside of a lab in 2017, and other labs have created similar systems. But even though isothermal tests have been put together in labs, they havent been manufactured on a large scale. We had a commercial partner who decided about three quarters of the way through that they did not want to commercialize our test, he says. It was the commercial market that actually caused the project which was technically successful to fail.
Now, dozens of companies are developing point of care tests for the novel coronavirus and are in different stages of development. For example, doctors at the University of California, San Diego are evaluating an experimental system that they say could return results in one hour; Mammoth Biosciences is developing a bedside test that would work similarly to a pregnancy test; and the biotechnology company Cepheid is leveraging their flu detection technology to build a rapid novel coronavirus test.
Normally, PCR methods work well. But in an infectious disease outbreak, when diagnosing patients quickly is so important, having the infrastructure to develop point of care tests would improve the response to this and future pandemics. The tools are there, for engineers. We have to put them together, which requires a lot of systems to work together, Klapperich says.
But a lack of sustained investment over the past few years means the technology these tests use isnt as well known as standard PCR and is still largely experimental. There isnt a pipeline in place to ramp up point of care testing and get it to health care facilities in the same way there is for PCR. Its also still not clear how exactly these types of tests compare with tried-and-true PCR. Thats not because we havent been yammering about this for a while, Yager says. Companies havent seen a real need. Until now.
Germany had 13 confirmed cases of the virus. The United States had 12, and the United Kingdom just 3. Sporting events, concerts and social gatherings were continuing as normal, and much of the world's population was blissfully unaware of the unprecedented crisis looming.
And for the remaining participants in the long-running reality series, that's how it has stayed.
The popular global reality TV franchise puts a group of strangers into a house for weeks on end, completely cutting off their contact with the outside world.
Producers have stuck to that principle even as borders have slammed shut, stock markets have sunk and the world has ground towards an unimaginable halt.
But on Tuesday evening, the contestants on the German program will finally be updated about the pandemic -- live, on television, in a heavily-publicized special episode of the show.
"Big Brother will give all contestants the latest information about COVID-19 in Germany and the whole world tonight," a spokesperson for the broadcaster Sat.1 told CNN, adding that the cast will be able to ask questions to the show's resident doctor.
"The first contestants had been cut off from the outside world in preparation for the show on February, 6th. Theoretically they could know about the virus outbreak in Wuhan/China but don't know anything about the current situation in Germany," the spokesperson added.
Newer contestants, who entered the show just days ago, have been banned from telling others about the pandemic.
The decision raises questions about how and when reality television should allow the real world in, and differs from the approach taken by other versions of the show. Some commentators online said the scenario resembled the 2008 British drama "Dead Set," in which contestants on the UK's "Big Brother" were unaware of a zombie apocalypse taking place outside.
On the Canadian version of the program, which is also currently on air, a viral clip from last week showed contestants speculating as to why there was no live audience to greet the latest person voted off the show. Mass gatherings have been scaled down and discouraged in Canada, as with other major countries.
"We would have seen them," one contestant is heard saying on the show, which constantly airs a live feed online. "Unless the house is now soundproof?" another suggests. Eventually, the Big Brother figure tells the contestants to "please stop talking" over the PA system.
But over the weekend, the feed was paused and the contestants on the show gathered in the living room, before a producer told them about the coronavirus outbreak over the PA, a spokeswoman for broadcaster Global TV told CNN.
"This just didn't feel like something you couldn't not tell everybody about," she explained. Producers ensured the contestants' families were unaffected, and contestants were checked for and cleared of coronavirus symptoms by the show's doctor.
BRUSSELS The gilded museum of Europe is hollow and echoing. The great squares and stadiums are empty, the museums shut, the churches hesitant about services, the fine restaurants and cool bars shuttered.
The coronavirus is not only spreading, but also infecting societies with a sense of insecurity, fear and fragmentation. Above all, it has severed humanity from its conceit of control and of the invincibility of its institutions, science, technology and democracies.
If that is true nearly everywhere the virus goes, it is all the more so in Europe, with its history of Enlightenment, where life is lived, ordinarily, on an intimate scale, bumping shoulders on the street or in the cafe, greeting friends with kisses on the cheeks.
No more. Today, Europeans are told to hide away, erecting borders between countries, inside their cities and neighborhoods, around their homes to protect themselves from their neighbors, even from their grandchildren.
Confronting a virus that respects no borders, this modern Europe without borders is building them everywhere. But different states have different answers, and each discrete and disparate step has increased the sense of the coming apart, and the feeling that the problem is someone elses creation.
The paradox of a virus that knows no borders is that the solution requires borders, not just between countries but within them, said Nathalie Tocci, an adviser to the European Union. But putting them up in an uncoordinated way doesnt help.
Putting them up at all, in fact, may not make much difference. The invisible threat is already within.
Even so, there is inevitably a turn back to the state for expertise, control and reassurance. As the pandemic spreads from Italy to Spain, France, Germany and beyond, there is a growing sense of the need for harsh, even authoritarian methods, many of them taken from China.
THE LATEST Read our live global coverage of the coronavirus outbreak.
After watching the epidemic in China with extraordinary indifference, Europe has been terrified by Italy. Suddenly, many of the continents countries are trying to lock down, to protect themselves and their citizens. The idea of European solidarity, and of a borderless Europe where citizens are free to travel and work, seems very far away.
If the pandemic has the logic of war, requiring strong action, the enemy may be the person standing next to you.
Its not anymore a question of borders between states, but between individuals, said Ivan Krastev, who directs the Center for Liberal Strategies in Sofia, Bulgaria, and is a permanent fellow at the Institute of Human Sciences in Vienna.
It is now the individual you fear, Mr. Krastev said. Everyone around you may be a danger, carrying the virus. The person may not know hes a danger to you, and the only one who isnt a danger is the one you never meet, the one who stays at home.
The welcoming kiss, la bise, is suddenly dangerous, as is the hug of happiness or condolence.
Mr. Krastev has written tellingly about Europes migration crisis, calling it as big a shock as the fall of Communism. But now no one is talking of opening borders, he said. Now its not migrants you fear, but everyone.
The narrative of the migrant crisis included metaphors of hordes, invasion and even insects, and claims that migrants were bringing disease. They wanted to come from their wretched lives to a Europe that they considered safe and rich. But it is no longer safe.
Now, migrants will wonder, Is the plague worse than the war? Mr. Krastev said. You cannot negotiate with the plague or flee it.
A decade ago, Dominique Mosi, a French political scientist married to an Italian, wrote a book called The Geopolitics of Emotion, explaining the strains caused by globalization in terms of humiliation, hope and fear. Today, he said, the dominating emotion is fear.
The crisis of Covid-19 is adding uncertainty to uncertainty, fear upon fear, accelerating a process of anxiety about a world that is moving too fast, Mr. Mosi said, referring to the disease caused by the new coronavirus.
With terrorism, economic panic, strategic uncertainty, climate change and migration, he said, the fundamentals seem uncertain and the future unknowable.
Now comes an enemy unseen. You can put your hand on a door handle and get the virus thats the maximum of fear, he said. He misses touching and kissing his grandchildren, he said, and begins to think of death.
Yet mobilization of society is even more difficult and necessary because the enemy is invisible, he said. Paris has lived through terrorism and saw 150 killed in one night in 2015, he noted. It was brutal but visible, he said, whereas in the end, the number of dead from the virus will be much more numerous, but its invisible, and weve never lived through that.
So it is difficult for governments who learned to urge calm on their populations in times of terrorism to now learn how to frighten them into acting for the common good.
During the great Black Death of the 14th century, which took so many lives, people believed that God had condemned those who died and chose whom to spare. But in a secular society its harder to find the morality in who is dying, Mr. Krastev said. Instead you have all these conspiracy theories, with talk of the foreign virus and even a Chinese spokesman suggesting that the American military was to blame.
In 2003, George Steiner, the European philosopher who died last month at 90, wrote a famous essay for the Nexus Institute called The Idea of Europe. But that idea is under threat.
Europes cultural identity, Mr. Steiner wrote, is founded on several characteristics largely missing in the United States, where car culture, suburban sprawl and great open spaces engender a sense of separateness.
In Europe, it is a culture of coffee houses and cafes, where people meet, read, write and plot. They are places, Mr. Steiner said, for assignation and conspiracy, for intellectual debate and gossip, for the flneur and the poet or metaphysician at his notebook, open to all.
Europes is also a pedestrian culture, founded on squares and small streets, usually named after scholars and statesmen, famous for their works and their massacres. Europe is walked, he wrote, and distances are on a human scale.
In this plague time, with cafes closed and squares empty of residents and tourists, both of those characteristics are destroyed, leading to isolation and loneliness, Mr. Krastev said.
But perhaps most important, Mr. Steiner wrote, is the European sense of death and decay, which he called an eschatological self-awareness which, I believe, may well be unique to European consciousness.
Deep in Christianity and European philosophy was a more or less tragic finality, he wrote, adding: It is as if Europe, unlike other civilizations, had intuited that it would one day collapse under the paradoxical weight of its achievements and the unparalleled wealth and complication of its history.
These are hardly the end of days, but the mood is grim. Still, it is sometimes broken by surprising acts of common humanity and solidarity, Ms. Tocci noted.
An Italian, she is staying at home in Rome with her husband and children, filling out a police form when she ventures out into the street, even to go to the grocery store, and trying to concentrate on the nicer aspects of quarantine.
You rediscover some small things, spending time with the children and the family, keeping up with her father by Skype, noting that for once, social media is proving to be more beneficial than meretricious.
Italians have been singing together from their segregated balconies and displaying a united appreciation for their exhausted medical workers, she noted.
Whats beautiful about it, so far, is that it hasnt led to alienation, Ms. Tocci said. People are afraid but mostly showing responsibility and solidarity. There are so many messages going around, some of them full of hilarity and a shared community.
Even on my dreary and empty Brussels street, someone has hung an Italian flag from an apartment window. And there are still, in the grocery stores, where people move silently and carefully around one another, moments of shared emotion. A woman with a full shopping cart was trying to balance a package of toilet paper and dropped her phone. I picked it up and gave it to her, then thought how foolish I had been, but she thanked me and smiled ruefully, understanding the ambivalence.
Mr. Krastev is trying to decide whether to stay in Vienna or uproot his family for a month to Bulgaria, where medical facilities are weaker but the virus seems less prevalent, and where he has a more traditional network of family and friends.
Where is the place of greater safety, a question for all refugees, he wondered. His daughter had just returned from Spain and didnt understand why she couldnt stay there. But I told her, The Spain you like will disappear in 48 hours.
Many noted La Peste, or The Plague, an allegorical novel published in 1947 by Albert Camus, seeing it as a lesson not just in how people behave in pandemics, but in how nature bursts forth to mock our pretenses.
When the bubonic plague finally lifts in his joyous city, the main character, Dr. Bernard Rieux, remembers that the illness never dies or disappears, but bides its time. Perhaps the day would come, he thinks, when, for the misfortune and instruction of men, the plague would rouse its rats and send them to die in a happy city.
Health officials and citizens in the United States and Europe are desperately trying to slow the spread of the Covid-19 coronavirus outbreak and are pleading with each other to practice social distancing and good hygiene.
Canceling events and family gatherings, closing schools, and reducing visits to public spaces and businesses are simple, powerful, and effective tactics to control disease transmission alongside testing to identify sick patients and isolate them from others.
And since the novel coronavirus is already spreading locally in several communities, epidemiologists say measures to limit the spread of Covid-19, the disease caused by the virus, are most effective right now in the early stage of the outbreak, when few people are infected and the most lives can be saved. Conversely, the disease becomes vastly more dangerous the longer the country waits to implement such measures, particularly since it can spread even before an infected person shows symptoms.
Countries like China and Italy found this out the hard way when they, seemingly overnight, experienced massive increases in the number of Covid-19 infections and deaths.
The math behind the outbreak explains why.
Right now, many places seeing Covid-19 transmission are following an exponential growth trajectory. That is, the rate of the spread of the infection is proportional to the number of people infected. Each infected person is expected to infect a certain number of people around 2.5 right now who each in turn go on to infect 2.5 more, and on and on, unless drastic measures are taken to reduce social contact and isolate the infected from others.
Think about counting doubles 1, 2, 4, 8, 16 and so on. How many times would you have to double to get to more than 1 million? 20. How many doubles to get to more than 16 million? 24.
So thats why Covid-19 appears to spread very slowly, and then all at once.
As epidemiologist Adam Kucharski pointed out on Twitter, this trend also shows how important it is to reduce the rate of infection early.
And individual actions can make a big difference. Reuters showed how one Covid-19 patient in South Korea, so-called Patient 31, had direct contact with 1,160 people and created new clusters of the infection. The lesson: Dont be Patient 31.
Of course, Covid-19 cant spread exponentially forever. There are upper limits to the population and over time, people start to build immunity to the disease and the infected start to recover, so theres a natural ceiling. As with many other disease outbreaks, there will likely be a peak and decline in the number of cases.
Nonetheless, its important to lower that peak and spread out the cases as much as possible. That buys valuable time for health providers, allowing them to acquire the tools they need like beds and ventilators while avoiding being overwhelmed by patients. Flattening the curve of cases over time can therefore save lives, and in places where the health care system is already close to capacity, its critical.
Taking drastic measures to limit the transmission rate of Covid-19, like closing schools, canceling public events, and sending people home from work, may seem like an overreaction when few people in a city or state are infected. However, early in the outbreak is exactly when such measures are most effective.
Using data from Hubei province, China, where the virus originated and where the vast majority of the Chinese cases were seen, designer Tomas Pueyo posted on Medium a conceptual model he created showing the difference even one day of social distancing can make in reducing the burden of cases. Vox has recreated the chart here (note that this is based on a theoretical model and not actual reported figures):
According to an epidemiological model visualized by the New York Times, one scenario is with no interventions, the number of infections in the United States reach 9.4 million. But with aggressive public health interventions starting today, that peak could fall to 3 million, according to the model. So the sooner such measures start, the bigger impact they will have.
In the race to develop a treatment for the rapidly spreading illness Covid-19, dozens of drugs are being tested around the world. Its an urgent mission because the latest data suggests that some 20 percent of people infected have serious illness, and around 1 percent may die.
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told Congress on Wednesday that Covid-19 is 10 times more lethal than the seasonal flu.
The danger stems from the pathogen itself: a virus called SARS-CoV-2.
Teeny tiny viruses are one of the biggest threats that humanity has ever faced. They are behind some of the most devastating pandemics ever known. Even with all of modern medicine, we have only eradicated one virus, smallpox, which required a decades-long global mass vaccination effort.
SARS-CoV-2, the brand new foe, is spreading fast even as entire countries, like Italy, are locking down to prevent its transmission. Estimates of its potential impact vary, but Brian Monahan, the attending physician of the US Congress, told lawmakers Wednesday he expects between 70 million and 150 million people in the US to get infected with the virus over time.
Right now, doctors are using general treatment measures to control the symptoms of Covid-19, but theres not yet a specific vaccine or cure.
Several factors make viruses like SARS-CoV-2 a particularly pernicious threat to humans. The good news is scientists have learned more about how they attack. Theyve also come up with ways to keep some of the deadliest of these tiny germs in check and are slowly inching toward cures. The question now is whether that research will bear fruit in time to blunt the blow of the Covid-19 pandemic and help us get ahead of the next outbreak.
Viruses are the most bizarre germs. Using just a handful of molecules, they assemble into all kinds of tiny shapes, and with just a small set of instructions, they can wreak havoc across entire ecosystems and threaten crop harvests. They can travel between hosts through the air, water, soil, and droplets. They mutate rapidly. And they are truly everywhere, from the oceans to the skies.
Compared to infectious agents like bacteria and fungi, viruses are much smaller and simpler. In fact, viruses can even make other germs sick. Yet theyre so simple that most scientists dont even consider them to be living organisms.
For instance, the poliovirus is just 30 nanometers wide. The SARS-CoV-2 virus behind Covid-19 is about 120 nanometers. Meanwhile, the E. coli bacterium is more than 16 times larger than SARS-CoV-2, and the human red blood cell is 64 times larger. A human cell uses 20,000 different types of proteins. HIV uses just 15. SARS-CoV-2 uses 33.
With all that extra space, larger pathogens like bacteria store the molecular tools they need to make copies of themselves and to fight off infections of their own. These tools are also what make bacteria vulnerable to antibiotics, drugs that interfere with molecular mechanisms in bacteria but not those of human cells, so they have a targeted effect.
But antibiotics dont work on viruses. Thats because viruses dont reproduce on their own. Rather, they invade cells and hijack their hosts machinery to make copies of themselves.
Bacteria are very different from us, so theres a lot of different targets for drugs. Viruses replicate in cells, so they use a lot of the same mechanisms that our cells do, said Diane Griffin, a professor of microbiology and immunology at the Bloomberg School of Public Health at Johns Hopkins University. So its been harder to find drugs that target the virus but dont damage the cell as well.
Theres also a huge variety of viruses, and they mutate quickly, so tailored treatments and vaccines against a virus can lose effectiveness over time.
Another factor that makes viruses so difficult to treat is how our bodies respond to them. Once the immune system detects a virus, it makes antibodies. These are proteins that attach to a virus or a virus-infected cell, marking it for destruction or preventing it from infecting new cells.
The problem is that a virus can cause a lot of damage and infect other people before the immune system readies its defenses. When those defenses kick in, they can cause other problems like fever and inflammation. And by the time these symptoms show up, the virus may already be in decline, or it may be too late to act.
Often at the time that virus diseases present themselves, its fairly far into the replication of that virus in that person, Griffin said. Many symptoms of the virus disease are actually manifestations of the immune response to the disease, so often things are sort of starting to get better at the time that you actually even figure out somebody has a virus infection.
Researchers use two broad strategies to combat viral infections: slowing down the damage from the virus, and speeding up and strengthening the bodys countermeasures.
Antiviral drugs are one approach to slowing down viruses. Like antibiotics, these are drugs that hamper the virus without causing much collateral damage. The majority of antivirals are targeting the viruses [themselves]. That means the components of the viruses, the viral enzymes, the surface proteins, said Pei-Yong Shi, a biochemistry and molecular biology professor at the University of Texas Medical Branch. By attacking different parts of the virus, antiviral compounds can prevent a virus from entering cells or they can interfere with its reproduction.
For example, remdesivir, under development by Gilead Sciences, is being studied as a way to treat Covid-19. It works by blocking the SARS-CoV-2 virus from copying its genetic material, RNA, the instructions the virus uses to replicate itself. Remdesivir resembles a component of RNA, but when its taken up by the virus, it causes the copying process to stop. Crucially, remdesivir fools the virus, but not human cells.
Protease inhibitors are another class of antiviral drugs, like lopinavir and ritonavir used to treat HIV (the -vir suffix is used to denote an antiviral drug, similar to how -cillin denotes an antibiotic). These compounds block an enzyme in the virus that normally trims proteins down, allowing the virus to infect other cells. When the enzyme is blocked, the virus doesnt mature properly, rendering it inert.
Researchers are also studying how to use antibodies to a given virus collected from engineered animals or from people previously infected with the same virus. By administering antibodies as a treatment, the recipients immune system can get a head start on identifying and eliminating the viral threat rather than waiting to build up its own antibodies.
There are also drugs like interferons that trigger a general immune response. These are a series of signaling molecules that make cells in the body more resistant to infection, inhibiting the spread of a virus while the rest of the immune system catches up. Its mainly used to control persistent infections like hepatitis B.
But interferons can have severe side effects like inflammation, so it requires fine-tuning to treat a virus without doing more harm than good. Doctors have used interferon with other antiviral drugs to treat Covid-19 in China and researchers are investigating this approach as another potential therapy.
Doctors can also use a number of different therapies to limit the immune systems response to viruses, like fever and inflammation, which can sometimes cause more damage to a patient than the virus itself. Anti-inflammatory drugs like corticosteroids and chloroquine are often used to lessen these symptoms.
And there are also vaccines for some viruses and efforts to develop new ones. These are treatments that coach the immune system to detect and fight off a virus before an infection takes place. These are powerful tools for controlling viruses across an entire population, but theyre tricky to optimize for a rapidly changing pathogen, and they require extensive, time-consuming testing to ensure they are safe for a wide segment of the population.
However, even if effective treatments enter the market, the virus will likely remain a threat. As weve learned with influenza (another respiratory disease caused by viruses), despite updated vaccines, new treatments, and a long history of public health responses, there are still between 12,000 and 60,000 flu deaths each year in the US. Covid-19 could remain a persistent threat, too.
To be clear, the best way to fight a virus is to prevent infections in the first place. And that depends on public health measures during an outbreak, like quarantines and social distancing, as well as personal tactics like robust, 20-second hand-washing with soap.
While there is a large and growing body of research on drugs to control viruses, they are still few and far between. We dont have that many antiviral drugs for acute infections, Griffin said. You often dont have any choice except to let it run its course.
Developing new drugs can take years of testing, and by then, an outbreak may have faded, or another more threatening pathogen may have emerged. Even viruses for which we do have antiviral drugs, like influenza, the illness often isnt detected in time to make it worth the treatment.
Other viruses like HIV can be controlled with drugs, but not eliminated, as hidden reservoirs of the virus remain in the body.
And within a population, there are always people who are more susceptible to infections, like people with depressed immune systems. For them, treatments and vaccines may not work, so they depend on the people around them to be immunized and to take proper infection control procedures.
All of which brings us back to prevention as the most effective way to combat viruses within a population. That means global coordinated action can be one of the best strategies to control the smallest pathogens. And simple tools like soap and water can be more effective at fighting a pandemic than the best drugs.
A woman mourns during a funeral held at Beheshte Masoumeh Cemetery for the victims of the new coronavirus in Qom, Iran, on March 17, 2020.
Photo: Fatemah Bahrami/Anadolu Agency via Getty Images
The U.S. government is run by sociopaths.
How else to explain the Trump administrations callous disregard for the lives of ordinary Iranians in the midst of this global coronavirus crisis? How else to make sense of U.S. officials doubling down in their support for crippling economic sanctions on the Islamic Republic, despite the sheer scale of the suffering?
The spread of Covid-19 has been nothing less than a catastrophe for the people of Iran. On Monday, Iranian officials reported another 129 fatalities, the largest one-day rise in deaths since it began battling the Middle Easts worst outbreak. Dozens of Iranian government officials, parliamentarians, and religious leaders have lost their lives to the disease. The death toll now stands at 988, and the total number of cases has crossed 16,000 roughly, nine out of every 10 cases in the Middle East! Globally, only China and South Korea have had more confirmed cases and yet, as the AP notes, the real number in Iran may be even higher.
To be clear: A lot of the responsibility for the death and suffering in Iran has to lie with the Iranian government, which has been grotesquely incompetent and deeply dishonest. The official response was glaring denial of the magnitude of the crisis, wrote Iranian doctors (and exiles) Kamiar and Arash Alaei in the New York Times earlier this month. The countrys supreme leader, Ayatollah Ali Khamenei, they noted, even accused the countrys enemies of exaggerating the threat of the coronavirus.
Nevertheless, U.S. sanctions on Iran, which have had a devastating impact on the economy, have made things much worse. The government has been forced to request an emergency $5 billion loan from the International Monetary Fund while Iranian President Hassan Rouhani has written to several world leaders to tell them how his countrys fight against the coronavirus has been severely hampered by US sanctions. His foreign minister Javad Zarif accused the U.S. government of medical terrorism.
The Trump administration in the form of Treasury Secretary Steve Mnuchin continues to insist that sanctions do not prevent humanitarian aid. This is, technically, correct. Yet as Human Rights Watch pointed out in October 2019, months before the novel coronavirus outbreak in Iran, while the US government has built exemptions for humanitarian imports into its sanctions regime in practice these exemptions have failed to offset the strong reluctance of US and European companies and banks to risk incurring sanctions and legal action by exporting or financing exempted humanitarian goods. The result, concluded the human rights group, has been to deny Iranians access to essential medicines and to impair their right to health.
Imagine being both so cruel and so unreasonable that you make George W. Bush and Dick Cheney look compassionate and reasonable in comparison.
In fact, as the Atlantic Council noted in May 2019, despite the fact that sanctions exempted humanitarian goods, the US Treasury Department had previously prosecuted medical companies for selling small amounts of medical supplies to Iran, which in turn, has had a deterring effect on other companies doing business with Tehran.
So it is any surprise, then, that Iranian suppliers of respiratory masks, surgical gowns, and ventilators are now saying they are out of stock? Or that the Iranian government is struggling to import the raw materials that it needs to manufacture antiviral drugs?
In late February, the Trump administration made a minor adjustment to the sanctions regime and allowed some humanitarian aid to arrive in Iran in coordination with the Swiss government. Sanctions relief, however, needs to go much further and much faster. As Rep. Ilhan Omar, one of the few progressive foreign policy voices on Capitol Hill, tweeted last week: We need to suspend these sanctions before more lives are lost.
Shes right. And there is precedent here: When a massive earthquake killed 26,000 people in the city of Bam, in southeastern Iran, in December 2003, the Bush administration allowed for a temporary suspension of sanctions. As journalist Negar Mortazavi has recounted, multiple U.S. military planes landed in Iran for the first time since the 1979 revolution and transferred over 150,000 pounds of medical supplies and more than 200 civilian personnel from Boston, Los Angeles, and Fairfax County in Virginia, to assist Iran in search and rescue, emergency surgery, and disaster response coordination.
Yet the Trump administration has refused to budge. Imagine being both so cruel and so unreasonable that you make George W. Bush and Dick Cheney look compassionate and reasonable in comparison.
On Monday, the Chinese and Russian governments demanded the U.S. suspend sanctions on Iran as a result of the pandemic. The Chinese foreign ministry called on the U.S. to immediately lift unilateral sanctions on the Islamic Republic, which it described as undermining the delivery of humanitarian aid by the UN and other organizations. Referring to illegal and anti-human U.S. sanctions, the Russian government accused Washington of purposefully cutting off millions of Iranian citizens from the possibility of purchasing necessary medical supplies.
Yet, again, the Trump administration has refused to budge. Imagine being both so cruel and so out of step with the international community that the Chinese and Russian governments have the moral high ground over you.
The unilateral reimposition of U.S. sanctions on Iran in 2018 was a clear violation of international law, according to the International Court of Justice. It was not mandated by the U.N. Security Council, and the U.N. Special Rapporteur on the effect of sanctions on human rights has since slammed the Trump administrations illegal and immoral forms of coercion, calling it an economic attack on the Iranian people.
Of course, an attack on the Islamic Republic is what the hawks in Washington have always craved. On Sunday, Trumps former national security adviser John Bolton was once again agitating for a new war with Iran. Meanwhile, Boltons former colleagues over at theneoconservative pressure group United Against Nuclear Iran, as Eli Clifton revealed, have been urging major pharmaceutical companies to end their Iran business, focusing on companies with special licenses most often under a broadly defined humanitarian exemption to conduct trade with Iran.
There is only one word to describe such behavior: sociopathic. Millions of Iranians, remember, could lose their lives from the virus.
But we have been here before. Brutal U.S. sanctions on Iraq in the 1990s caused the deaths of hundreds of thousands of innocent Iraqi children. Multiple senior U.N. humanitarian officials quit in protest of the policy, with one of them denouncing it as genocide.
And the U.S. governments response? We think the price is worth it, declared then Secretary of State Madeleine Albright.
As ordinary Americans line up at grocery stores and pharmacies across the United States to stock up on prescription medications, do they have any clue that their Iranian counterparts are being denied medicines and basic goods because of U.S. government policy? And as the number of deaths in Iran from Covid-19 continues to soar, exacerbated by a horrific U.S. economic embargo, do ordinary Americans think the price is worth it?
These conditions can limit underlying reserve and lead to worse outcomes when older people become severely ill, which taxes all organ systems, said Dr. Annie Luetkemeyer, an infectious diseases specialist at Zuckerberg San Francisco General Hospital.
For example, diabetes can make it harder to fight infection, and underlying heart or lung disease may make it more difficult for those organs to keep up with demands created by a serious Covid-19 infection, she said, referring to the syndrome caused by the new coronavirus.
Dr. Daniel Winetsky, an infectious diseases fellow at Columbia University in New York, said his advice to his own parents, who live across the country in San Francisco, has shifted dramatically. A week ago, he said, he was reassuring them about their safety, even encouraging them to go ahead with a trip they were planning to the Florida Everglades with a small tour group.
Over the weekend, his fears about the pandemic rose, and by Tuesday not only was he telling them not to go, but he also was advising them to reduce to a minimum the number of people they came into contact with. Visits with grandchildren are verboten.
Dr. Winetsky told his mother, Carol, who is 73 and has asthma, to stop meeting with her biweekly knitting group. And he instructed his father, Hank, who has had two coronary stents, not to attend either of his two book group meetings.
His mother continues to go to the grocery store, while avoiding crowded places like Costco. With her sons permission, she still goes to physical therapy for a back injury, but she is careful to make sure the therapist washes her hands and that the equipment gets wiped down with disinfectant.
Some experts are recommending that older adults at risk cancel nonessential doctors appointments, including wellness visits. Telemedicine sessions, if available, are often a reasonable substitute.
But an Army study found no difference in morbidity and mortality between camps that did and did not follow orders, because over time most became sloppy. Further investigation found that only a tiny number of camps rigidly enforced measures.
For interventions to work, people have to comply and they have to sustain that compliance; most of that depends on voluntary efforts and individual behavior. Army camps in wartime failed to sustain compliance, so it will be an enormous challenge for civilian communities in peacetime to do so. At the height of the H1N1 outbreak, Mexico City urged mask usage on public transit and distributed free masks. Usage peaked at 65 percent; 10 days later it was at 10 percent.
Today we are still trying to stop the disease from becoming deeply entrenched. If that fails, we will need tougher measures. Scott Gottlieb, a former commissioner of the Food and Drug Administration, has talked of states shutting down their economies. Thats whats going to need to happen, he said. Close businesses, close large gatherings, close theaters, cancel events. All of that happened in 1918 in most cities. On Monday, after initially calling for limiting gatherings to 250 people a recommendation based on a desire not to disrupt rather than on modeling the federal government finally recommended that no more than 10 people gather.
But many cities and states have yet to take stringent action. They should, and now.
In 1918 many cities imposed restrictions, lifted them too soon, then reimposed them. Covid-19s average incubation period is more than double influenzas, so compliance may have to be sustained for months, and openings and closings may also have to be repeated. Again, if the public is going to comply over time, they will have to be led, inspired or compelled.
That brings us back to the most important lesson of 1918, one that all the working groups on pandemic planning agreed upon: Tell the truth. That instruction is built into the federal pandemic preparedness plans and the plan for every state and territory.
In 1918, pressured to maintain wartime morale, neither national nor local government officials told the truth. The disease was called Spanish flu, and one national public-health leader said, This is ordinary influenza by another name. Most local health commissioners followed that lead. Newspapers echoed them. After Philadelphia began digging mass graves; closed schools, saloons and theaters; and banned public gatherings, one newspaper even wrote: This is not a public health measure. There is no cause for alarm.
Trust in authority disintegrated, and at its core, society is based on trust. Not knowing whom or what to believe, people also lost trust in one another. They became alienated, isolated. Intimacy was destroyed. You had no school life, you had no church life, you had nothing, a survivor recalled. People were afraid to kiss one another, people were afraid to eat with one another. Some people actually starved to death because no one would deliver food to them.
