First the good news. The pandemic will end sometime, because they always do. There are three ways in which it could end. Firstly, with a vaccine or a really effective treatment for the severe cases. This is the best case scenario, and the only questions would be, in the meantime, who and how many would die of it, or be left permanently crippled by it; and whether the world economy can recover.

Secondly, it could go on for years, with countries managing it as best they can, containing it where possible, or if not, trying to protect those who would be most severely affected. This would involve a considerable number of deaths, before it mutates to something different, which could be to a milder form or (hopefully not) into something even worse. This is where we are at the moment.

Thirdly, it could end because everyone has either had it and died or got immunity. This is how the 1918 flu virus ended. Similar strains have frequently emerged since and caused quite a few deaths, but that virus is no longer around. This is the “herd immunity” strategy.

Of these the far most palatable is the first, and I have high hopes there will be such a breakthrough. Of the two possibilities, vaccine or treatment, I personally think the treatment option would be the more useful. The hallmark of this virus compared with all other respiratory tract viruses is that, as we know, it is a mild illness for most fit young people, and disproportionately attacks older people and those with “pre-existing conditions”, as the phrase goes. If the virus progresses to its second stage, where the immune system appears to go into overdrive, then perhaps only 50% will recover, and many of these will suffer long term sequelae. If this stage can be targeted by new drugs, then this would be the best way of protecting those elderly and vulnerable. As soon as they show signs of severe illness and need intensive care we might have drugs which might both prevent it getting worse and treating it quickly, stopping the severe damage caused by this second stage. Because of the unique way the virus enters body cells, I am confident that sooner or later we will get such a drug, or more likely, drugs, in combination. We did it for AIDS, which was again a deadly killer, worse than coronavirus. Indeed, as I was writing this, came the news that dexamethasone has been found to reduce death rates slightly in the most severely ill. This is excellent news, although not surprising. It is the obvious choice for severe inflammation of any sort. Possibly it has been used many times by doctors “off label”, since the pandemic began, with benefit to some patients already. Of course it was essential to have a proper clinical trial to prove it worked, and so it is great news that it has been proved to be successful so conclusively. More drugs will need to be developed though, especially to find something that will prevent this second stage of the disease entirely. It might take a while. The countries which have tackled it early, such as Taiwan, New Zealand and so on will have won out, because they will have saved tens of thousands of their citizens from an early death – if they can continue to keep the virus away in the meantime.

A vaccine, on the other hand, works far less well for the elderly than it does for the young and fit, because their immune systems are often so weak. So it would protect the young and fit, who don’t need protecting from the virus itself, and only when herd immunity has built up through the community will the elderly themselves be totally protected. This in turn means that the whole world would have to be immunised, and that would require organisation, cooperation and an absence of corruption. These traits are not obvious in the world as we know it.

So in the meantime, what can we do? I think we need to recognise why this virus is so novel and why it has arrived just now. If we think of the virus world as organisms trying to get a foothold in an ecological system so that they can multiply exponentially as soon as possible (which is what they do) then this virus has identified with terrifying accuracy the weak spots in humanity in the twenty first century. Firstly, there are far too many of us. We are probably nearing the end game of unrestrained growth on this planet, and the global system of feeding ourselves is beginning to fray. It’s no coincidence that this virus was born in a food market. Irrespective of coronavirus, we are approaching the horrors of overpopulation which can befall any species – famine, plague, war, or any combination of these. But we have technology on our side and we have an extremely effective system of health care across the whole world. Some people think that this will keep us safe forever. Good luck with that. So very cleverly, this virus has found a way of attacking our new weak points.

When I started in medical practice in 1970, the population looked very different from now. People in general were thinner, (there were very fat people, but far fewer of them), they ate very simple food, especially after the war; and there was very little processed food, except perhaps the ubiquitous Spam. High blood pressure was very rare, but also very severe as we didn’t recognise the milder forms as being a problem, and diabetes also quite rare. Heart attacks and strokes killed huge number of men at very young ages, as did peptic ulcers. Respiratory disease was rife because of smoking and pollution at work, especially in the mines; and in the atmosphere. Life expectancy was much shorter. Over my time in practice, most of these diseases were tackled spectacularly well, and life expectancy rose rapidly. But few diseases, usually infections, were completely beaten, and so from the 80’s upwards people began living longer with long term conditions, sometimes taking very expensive medication. Nowadays it is the exception rather than the rule for the over 60’s to not take any medication at all. This is the population that the virus has found a way to target, through the ACE receptor. We medics first heard of the ACE protein in the 80’s with the advent of a new drug to tackle high blood pressure, and these drugs, called ACE-inhibitors, were very effective in preventing the long term effects of high blood pressure on the cardiovascular system and heart. But just as we were learning to treat and prevent the epidemic of heart attacks, very successfully indeed (although we were never quite sure how we did it ) we human beings in the developed world, developed things further in order to feed the hordes of new people who were being born, and surviving. This involved energy- intensive factory farming, and in order to make it cheap, food companies added more and more sugar, low quality fats and excessive salt to our diets. It took a long time for scientists to realise that it was sugar not fat that was causing the obesity epidemic, and therefore the diabetes epidemic. And now what do we find? The people who are targeted by this virus for especial harm are the obese and people with diabetes and heart problems. It isn’t a coincidence. While we are not sure of the exact relationship between the way the virus gets in to the body and the people who suffer from it the most, there is no doubt that they are the victims. So the virus is finding the weakest leak in humanity – those who have suffered from the consumption of poor quality food, have become obese and often have diabetes, heart and circulation problems and are being kept alive by modern medication. Of course this is an oversimplification. But the link is clear.


There are other risk factors that the virus rather likes – male sex, poor immune systems due to disease, and, it seems, black and minority ethnic people. The excessive risk for men versus women seems to be because women have two x chromosomes which have more genes for coding healthy immune systems. Nothing we can do about that, I am afraid. And any one with a chronic disease, especially cancer or leukaemia, is very vulnerable. Transplant patients whose immune systems are deliberatively weakened to prevent their own cells attacking the transplant. are also at great risk. They must all be protected while we wait for salvation by technology. But the problems BAME people face are interesting. It is becoming very clear that it isn’t because the virus targets such people because of race. There is no racial gene here. If it were so, you might find that people of African descent might have the lowest death toll from coronavirus, not the highest, as the prevalence of diabetes in countries of SubSaharan Africa is the lowest in the world, between 4 and 6 %. But in Africa, as in the rest of the world, urbanization leads to a change in diet towards the highly processed food, full of sugar, refined carbohydrates and low quality fat that we eat in the west, so that urban dwellers have a higher incidence of obesity diabetes, hypertension and cardiac problems, than in rural areas. And the same thing happens when present day Africans, and previously their ancestors, migrated to higher income countries of the west. Unfortunately on average they did not partake of the higher incomes in their new homes and now often lIve in relative poverty. So their incidence of chronic disease such as diabetes and cardiovascular diseases rises, and that, together with their increased exposure through their low paid work to the virus as front line workers, explains the very high death toll amongst black workers in New York and other cities in America and in the NHS workforce in the NHS in Britain.

So, to recap, I have seen in my lifetime a cohort of people come into existence who have been damaged by human progress, in that their food choices have been constrained by the need to supply ever more people as cheaply as possible. They then become dependant on the ability of modern medicine to keep them alive. Up to now we have tolerated this situation – even congratulated ourselves on our long lives, those of us now in retirement anyway. But the virus has evolved to hit these people hardest. However optimistic we can be that we will develop treatments and vaccines to beat it, I think it is inevitable that the increase in longevity that we have all taken for granted will stall (actually it had already stalled due to austerity), and then fall quite substantially, but probably most rapidly amongst the poor. And for those who are rich, and also very risk averse, there will be a considerable reduction in enjoyment of living.

Up to now, feeding the world has been a success story in that we have greatly reduced starvation and malnutrition all over the world, even though the population has been rising very fast. Our methods of farming have developed using copious supplies of energy from fossil fuels, 30% of all ice-free land, and 70% of available freshwater. But livestock is the world’s largest user of land resources, representing almost 80% of the total agricultural land. One-third of global arable land is used to grow feed, while 26% of the Earth’s ice-free terrestrial surface is used for grazing. And there are likely to be 2.3 billion more people in the next four decades. So we need to take a hard look at ourselves. Maybe it is inevitable that feeding large populations cheaply will have side effects, such that they can be exploited by ever new viruses. But changes will have to be made, to reduce the amount of meat we eat, change to other sources of protein, and reduce waste. Can this be done in the present Ponzi scheme system of more and more people consuming more and more of everything? On a finite planet? Of course not. We also really have to address the problem of overpopulation as well as of overconsumption. Big time. But will we do it? Not with insufficiently regulated market forces for sure, which are poisoning our world in so many places. I do hope that eventually after some years of living with this virus we will have the courage to change our ways, because otherwise our lives are likely to be changed in even worse ways. We are running out of time, and this virus is the first of so many challenges we will have to face. Let’s hope we rise to this one at least.