Over the past month, Dr. John Campbell, an unassuming lecturer, resource developer and clinical staff nurse based in Cumbria, UK has become an invaluable source of information on the COVID-19 pandemic for millions of people around world.

Dr. Campbell, who worked for over 27 years for the University of Cumbria, graduated with a PhD from the University of Bolton in 2013 and is the author of several textbooks on physiology and pathophysiology as well as numerous teaching videos.

Viral Videos

Remarkably, Dr. Campbell’s own Youtube channel leads the World Health Organization’s channel by 29 million to 26 million lifetime views (as of 3 March 2020).

The quirky titles of Dr. Campbell’s videos – “6 February”, “11th News” and “Monday Lunch time” are three typical examples – seem more designed to evade detection than to go viral. In a time when people are hungry for unvarnished analysis of the latest data and scientific findings on the pandemic, his frequent video updates are clearly meeting a vital need.

We asked Dr. Campbell what first piqued his interest in COVID-19.

When I first started looking at it, it looked like it was being quite transmissible. Then I realised … that it was transmissible in the early stages when someone was presymptomatic … I realised that that was different to previous coronaviruses. The SARS Outbreak … was able to be contained, but the difference was that [those that caught it] became symptomatic and then became infectious. So, when people were incubating SARS 1, they were hardly infective at all. Then they get ill and they become progressively more infective. They’re most infectious and shed most virus in the second week. The thing with that is that you could see that they were ill, so they would be lying around groaning and not feeling very happy with themselves. Then you say, “Oh, look, they’ve got SARS, and they’re acutely ill.” But now, someone could be infectious who gets up in the morning, who has a shave, and goes to work, and does a day’s work, … because the infection’s in its presymptomatic phase. Realising that, it seemed there was going to be the likelihood of spread there. The other thing that concerned me was that in the early stages, the World Health Organisation said that there shouldn’t be any flights in and out of Wuhan and Hubei Province, but that flights to China were possible. By the end of January, or rather before that, I realised that this was Chinese New Year, which I believe fell on the 25 January. If you know anything about Chinese culture, that involves an awful lot of toing and froing. Basically, everyone has to go to their hometown. It’s the major cultural holiday event of the year in China: it’s a bit like Christmas and Easter all rolled into one. So, you’ve got this transmissabililty characteristic, and you’ve got this social background of travelling around the country in China. You’ve also got the phenomenon where people tend to work away from home sometimes for weeks or months of the year. Some people even work away for a full year, and just go home for New Year. It’s not something that people like to miss. Basically, half of China mobilises. Of course, Wuhan is a major city with a population of over 11 million. That means there’s going to be an awful lot of people who work in Wuhan going back to their home villages, and also people from other parts going to Wuhan for the Chinese New Year, who will then be returning back to their places of work in the days after that essentially carrying the virus with them. The combination of that sort of social background and the transmissibility of it made me think, ‘Wait a minute! We could have a problem here.’ So that kind of got me into starting to look at it. Basically, I have taught nurses for twenty-seven years, that’s my job. I know how to communicate health-related concepts. I started reading some medical journals, the Lancet and things like that, and there was some fascinating material about the virus in those written primarily for doctors and academics. What I’ve tried to do is take that information and translate that into material that is both interesting, but also intelligible for the average intelligent, interested non-professional watcher, because these are the people that we need to get on side with this. We need to mobilise public opinion if behaviour is going to change.

Chinese Lessons

The earliest known case of COVID-19 is believed to be a patient who reported to the Jinyintan Hospital in Wuhan, China on 1 December 2019. Since that time, official Chinese data states that have been almost 80,000 cases with almost 3000 deaths, with the actual number of cases likely to be considerably higher for various reasons, including asymptomatic infections.

After an initial denial phase, the Chinese response has been extremely vigorous. We asked Dr. Campbell what the lessons other countries can draw from the Chinese experience of battling COVID-19.

There are two absolutely massive lessons here. The first one is that initially this was covered up by local officials. There is no question about that. Dr. Li Wenliang was essentially forced to retract statements that he made that we were dealing with a new SARS-type viral pneumonia. He was oppressed by local authorities. Now the local authorities seem to be terrified of the more senior authorities. I am assuming they were thinking that the more senior authorities would say, ‘Well, this virus cropped up on your watch, therefore you’re to blame.’ Therefore, there was this kind of denial strategy. So, the huge lesson there is the absolute necessity of early transparency, and the absolute necessity of taking medical and scientific opinion. Medical and scientific opinion on medical and scientific matters should always trump political opinion; and, that did not happen. And that gave the disease time to double probably every five or six days for presumably three or four weeks, and allowed people to carry on travelling around China who were infected when they were in this denial stage. So, that lack of transparency, and the pre-eminence of political thinking over medical and scientific thinking was one massive lesson to learn. We have to listen to our doctors. We have to listen to our scientists. That’s one thing. Now, the second lesson is that once the senior authorities in China realised what was going on, they started mobilising the power of the Chinese state, and did an absolutely unbelievable job. They built a hospital or two hospitals … in ten days. In doing so, they were able to treat many of the sick people, and saved hundreds if not thousands of lives. They poured resources into Hubei and Wuhan from all parts of China. That would have dramatically reduced the case fatality rate by the quality care they were given. The other brilliant thing the Chinese did was once they realised the transmissibility characteristics of the virus, they instigated massive programmes of social isolation. They extended the New Year holiday. People weren’t obliged to go back to work. Initially, it was locally, but now it is all over China. I’ve had emails from people in Shanghai and Beijing, and all of them are basically restricted to their homes. They can only leave their block of flats or their immediate residence area with a pass. They’re screened when they go out. They’re screened when they enter the supermarket. Then, as soon as they’ve been to the supermarket, they have to leave and go home. Even then they can go out once every three days. Now that seems draconian to us, but this social isolation is the only way to stop the spread, because this disease is now only spread from human to human. So, isolating humans is the only way to do it. The other thing that the Chinese did was they had excellent testing from the Chinese Centre for Disease Control. So, people were tested, and if they weren’t ill, as most people aren’t (thankfully 80% of people get a mild illness) they were just managed at home with an agreement – a gentleman’s agreement, if you like – that they would remain in self-isolation at home, which is the correct thing to do. But if someone was actually found to be positive they would put paper over the door, at least in Shanghai they did it this way from emails I’ve received. They would provide food through the windows of the flat. Then the paper would be checked every day to make sure they had maintained the isolation. Now if it was broken then my understanding is, from the emails that I got, that they would be warned not to do that again, and if it was broken again only then would they be removed to a government quarantine isolation centre. So, it seems to be that the Chinese state did an incredible job. Private cars were banned in Wuhan. Resources were mobilised on a massive scale. So, for example, in China it’s a legal requirement to wear a mask outside. So, initially there was quite a big black market in masks, and the Chinese Government clamped down on that, and made masks available, three masks per person, through local official outlets, at very much a token cost that anyone could afford. There’s a biphasal thing going on here. The Chinese infrastructure was very harmful in the beginning, and that was bad because it allowed the cluster, but once it went to more senior levels, there was top-down organisation and local officials were kicked into touch. … Each residential area in China will have a security guard – basically a party person, but that’s good, because it keeps down petty crime. Because there is this hierarchical infrastructure, they were able to organise that. They could soon instigate computerised systems where people had to donk in and donk out their block of flats.

Beyond China, other countries are unlikely to be able or willing to replicate fully the positive aspects of the Chinese response for various cultural, social or economic reasons. For one thing, no other country has China’s manufacturing base and capacity to increase production rapidly, so the challenges faced by other countries in slowing the contagion have the potential to be even greater.

Furthermore, it is clear that even if other countries’ financial resources were unlimited, the rapid geographical spread of the pandemic and the disruption to global supply chains is presenting unique challenges in optimally resourcing the frontline medical response. If medical resourcing presents challenges to the UK, Germany and Japan, how much more so will it stretch developing countries with limited production, infrastructure, skilled medics and financial resources.

That’s a concern that I’ve had all the way through that poorer countries are not going to have the infrastructure to be able to deal with it. They won’t have the testing facilities. So, when people get sick, it might be difficult to work out whether the virus or something else has caused the infection. This is presenting in a very similar way to other conditions. So, that’s going to be one problem. Countries with weaker healthcare systems just aren’t going to be able to care for the people that are sick. Also, these are the same poorer countries that often have quite crowded conditions anyway. Once there is community spread there, once it is spreading from person to person in those areas, a big cluster is likely to develop fairly quickly; probably that won’t be identified for some period of time. That’s going to spread it to other people. As well as that, the people that get poorly – the 12% or so that get really sick with this – aren’t going to get the medical care that they would ideally receive. Therefore, the case fatality rate is going to be higher. So that’s going to be a huge problem. There was actually a paper published in the Lancet a few days ago just about this, talking about the problem in African countries. Basically, it says that there needs to be a pan-African approach to this. So, in other words, if Kenya gets its act together, but Mozambique doesn’t, then the virus isn’t going to stop when it gets to the Mozambique border; it’s just going to spread to Kenya. So, there needs to be a unified approach against this common enemy. Dr. Tedros from the World Health Organisation said if there were aliens coming from space that would unify the human race. Here, this is what we need again, because we now have a common enemy. Countries need to work together in a unified way. There needs to be political will, and sharing of information and resources. Now given the political history that we see in certain parts of the world, including indeed our part of the world, but particularly you might think of African situations, you have to ask your readers if that level of cooperation is likely to emerge in the next few weeks, because we haven’t got that long to sort this out.

Secondary Clusters

Outside of China, the largest secondary clusters were in South Korea, Iran and Italy, with 5186, 2336 and 2036 reported cases respectively, as of early afternoon on 3 March 2020.

The Iranian and Italian clusters are significant in appearing to have served as transitional nodes to subsequent outbreaks in other countries. Egypt while only reporting two confirmed positive diagnoses currently appears to have been the locus whence recently identified cases in California and Ontario contracted the virus.

We asked Dr. Campbell for his thoughts on the Iranian and Italian clusters, and what might be going on in Egypt.

Egypt and South Africa have got a lot of traffic going back and forward between themselves and China as indeed a lot of other African countries have, such as Kenya, Tanzania and Nigeria. The reason being that the Chinese have got many massive infrastructure projects that they are developing. So, for example, they recently opened a railway line from Mombasa to Nairobi. They built it in about a couple of years or something. Very impressive infrastructure, but that means an awful lot of going back and forward with Chinese engineers going to African countries. So somewhere like Egypt, now I don’t know specifically what their testing facility is, but most people in Egypt who get sick would not necessarily see a competent doctor. They would probably not have access to COVID-19 testing, or it would certainly be limited, therefore … although there is only one official case, it is quite conceivable that there have been many cases that have simply not been recognised. Even in the United States, this is the case. There was a study just yesterday where some geneticists looked at a viral strain in two parts of the western United States and found that there were great similarities in the genetics for the viruses infecting the two people. From that they inferred that [their infections] came from a common source, and from that they inferred that there had probably been spread on the west coast of the United States for the past six weeks. If that’s the case in the United States, it could certainly be the case in many African countries. Unfortunately, I do suspect that there are unrecognised cases in several African countries at the moment. That is certainly a possibility that needs to be considered. So, there is a very major case for improving testing capacity in these countries.

So what are the options for policymakers in poorer countries? How effective are quarantines, lockdowns and the like?

We know that social isolations measures in China were implemented and shortly after that the number of new cases dropped quite dramatically. Now I believe that that is cause and effect. I believe that the social isolation strategies that affected hundreds of millions of people were the cause of the reduced rates of spread. So, what we need to do is slow this down and stop so many people getting it all of a sudden, and we know that social isolation will do that. Now in poorer countries where people are living hand-to-mouth, where what you eat that evening depends on what you did that day, that’s very difficult to do. The economics are really against social isolation, because people simply can’t afford to stay at home for a week.

Surely a particular government reaches a point at some point where they say, ‘Probably we’ve just got to let this run through the population’?

Well, I hope there’s not that sort of defeatist attitude, because what that will mean is many people will get it all at the same time, and we won’t be able to manage the sick people all at the same time. We need to slow this down and spread it out as much as we can to make it more manageable. The model that Imperial College [developed] estimated that 60% of the world’s population could be exposed to this virus in the next twelve months. If that’s the case, perhaps 30% will be symptomatic, and we think about 12% of those would get severe disease. If you want to get your calculator out, you get some pretty frightening numbers out of that.

Critical Care, Critical Shortages

A 2012 study by Rhodes et al found that there were 11.5 critical care beds per 100,000 head of population across Europe. This equates to around one per 8700 persons, although there were wide country-to-country variations.

According to the Society of Critical Care Medicine, in 2015, “the United States had 4862 acute care registered hospitals; 2814 of these had at least 10 acute care beds and at least 1 ICU bed. These hospitals had a total of 540,668 staffed beds and 94,837 ICU beds (14.3% ICU beds/total beds) in 5229 ICUs. There were 46,490 medical-surgical beds in 2644 units, 14,731 cardiac beds in 976 units, 6588 other beds in 379 units, 4698 pediatric beds in 307 units, and 22,330 neonatal beds in 920 units.”

With the US population standing at 320.6 million on 1 July 2015, these figures imply that there was around one counted ICU bed in the United States per 3381 head of population with an occupancy rate of 68%. In other words, at any one time there would have been in the region of 30,000 spare ICU beds across the United States, many of which would be unsuitable for adults suffering from COVID-19 infection. The numbers today, five years later, are likely to be broadly comparable.

Furthermore, a 2016 survey of epidemiology, patterns of care and mortality for patients with Acute Respiratory Distress Syndrome (ARDS), one of the comorbidities of COVID-19 infection, found that “unadjusted ICU and hospital mortality from ARDS were 35.3% … and 40.0% … respectively”. It is not uncommon for patients to require weeks of mechanical ventilation. It is clear that a significant percentage of those who contract COVID-19 require intensive, often weeks-long intervention.

Globally, there’s just not the capacity in terms of intensive care units. We haven’t got the capacity here [in the United Kingdom]. I think last Friday there were fifty intensive care beds in country free! When people are sick, there are going to be lots of levels of medical intervention that they might require. There was a case that I know of where the two people that had the disease just needed small amounts of supplementary oxygen for a day or two. So that was a relatively minor medical intervention. A low level of oxygen of, say, two litres a minute for a day or two. Other people might need five litres of oxygen a minute for a day or two. Other people might need five litres of oxygen for several days. What that means is that we’re going to need one heck of a lot of oxygen! Other people might have secondary bacterial infections. So, as well as oxygen they might need intravenous antibiotics. If they have secondary infections, some people might need intravenous fluids. So, some people might need oxygen; some people might need oxygen and intravenous antibiotics; and, some people might need oxygen, intravenous antibiotics and intravenous fluids. So, you see there’s going to be a complete gradation in the amount of medical care that people will require from fairly minor intervention all the way through to high-dependency intensive care with intubation and ventilation. It’s going to be a spectrum of intervention that’s required for this 12% of so that get more severe disease. I actually looked at the figures in Italy today. I worked out the percentages. Now the BBC news reporter gave the number of people that were on intensive care, and I worked that out at 8.2% of the total number of people diagnosed. But when a BBC reporter says “intensive care”, they probably don’t mean what I would mean by intensive care. They just mean a degree of hospital care. I don’t know. I don’t have that data. There’s going to be a gradation of increasing levels of medical intervention that various people will require in order not to die, and if they don’t get that, the case fatality rate is going to climb dramatically.

Given the potential for advanced healthcare systems to be overwhelmed, and given that there is not the capacity in many places to deal with simpler conditions as things stand, we asked what the options were for dealing with or mitigating symptoms once a person has already been infected in a situation where they are not able to access professional medical care.

Most people will just have a fairly mild illness, will just go to bed for a few days, then feel a bit rough for a week, then be okay: that’s what we believe. Now, if people have severe illness at home that is caused by a severe form of viral pneumonia, the infiltration of fluid into the lungs, that means they might need assistance in breathing and might need oxygen. Now, because there’s no specific antiviral therapies, that’s going to be very difficult to do at home. So, if someone didn’t have access to medical care, in the third world, for example, or in a situation where there were very many people infected … this is what would make sense to me. (I’m not saying this is NICE guidelines or anything; NICE hasn’t published as yet I don’t think, but it’ll be interesting to see if they come up with something quite soon.) If you’ve got breathing difficulties, you might find it easier to breathe when you’re sitting up. Or, possibly you might find it easier to breathe if you’re sitting up and leaning forward on something. You might find it easier to breathe it you’re breathing 21% oxygen from fresh air from outside, because the concentration of oxygen in room air can go down. So, if you’re breathing fresh air, you’re breathing 20.8% oxygen which is in the atmospheric air. Keep hydrated! If you feel like eating, my personal advice would be to eat. If you don’t feel like eating, my personal advice would be don’t worry about it, for a few days, for most people. Eat what everyone thinks to be a healthy diet. Fruit and vegetables are going to contain flavonoids, which are generally good for you. Now lack of certain nutrients will reduce the efficiency of the immune system. People that are malnourished are going to be immunocompromised. Having said that, in the UK, most of us aren’t. So, taking extra nutrients is probably not going to help. If you’re short of vitamin C, that might be a problem. Some people say ‘Take huge doses of vitamin C!’ but I don’t know of any evidence that would help. So, just take enough to make sure you’re not malnourished. The only real exception I would make to that is, in the UK, we don’t make enough vitamin D from sunshine over winter. So NICE guidelines recommend up to 25 micrograms of vitamin D a day as a supplement.

Vitamin D is one of the few supplements that the UK’s National Institute for Health and Care Excellence (NICE) actively encourages healthy individuals to take regularly. According to NICE, “It is important to maintain dietary intake of vitamin D by taking vitamin D supplements, especially during the winter months, as it is difficult to obtain sufficient vitamin D from food sources alone because they are limited. Rich sources include cod liver oil (this also contains vitamin A which can be harmful in high doses and should be avoided in pregnancy), oily fish (such as salmon, mackerel, and sardines). Egg yolk, meat, offal, milk, mushrooms, and fortified foods (such as fat spreads and some breakfast cereals and yoghurts) contain small amounts.”

The point is we don’t make it over winter. It’s quite common if you measure vitamin D levels to see that they go down in people over winter. There are vitamin D receptors in many different parts of the immune system. So, it’s strongly suggested, and there is some evidence for it, that vitamin D is necessary to maintain immune function. Now again, if you’re deficient in it, if you’re low in vitamin D, that will reduce the efficiency of your immune system. If you take more vitamin D than you need, that will not boost your immune system. That’s the only thing that people are likely to be short of in the UK. The darker coloured skin someone has, the more likely they are to be short of vitamin D, because darker coloured skin will make vitamin D in exposure to sunshine particularly slowly. So Islamic women that wear a lot of covering and that are only exposed to a little bit of faint English sun are very exposed to deficiency in vitamin D. Having said that, I don’t know what colour you are, but I am a white man, and I still get very low vitamin D in winter, just because you run out of it. So, vitamin D is important.

It was suggested that over the past couple of hundred years living patterns have perhaps also changed so that we’re spending more time inside, and that fewer people have occupations that require them to be outdoors.

There’s been so much publicity about melanoma that people tend to avoid the sun full stop. It would take ten minutes to explain this, but avoiding the sun full stop is not the right thing to do. We don’t want to get sunburnt for sure, but it’s not the right thing to do. The other thing for immunity is sleep. It looks like people that get good sleep have better immunity than people that don’t get good sleep. And the other thing is stress. Stress hormones, adrenaline and cortisol, are probably going to reduce the efficiency of the immune system.

So what about traditional remedies, such as ocha root or elderberries?

I know of no drug or supplement that has known COVID-19 antiviral properties. Now having said that, the Chinese are currently conducting, I think, 82 clinical trials as we speak. That is testing everything from some traditional Chinese medicines all the way through to antiviral drugs. So, for example there’s an antiviral drug, Remdesivir that was developed for Ebola, and there’s some evidence that that might be helpful. The other one is Chloroquine, an old-fashioned malaria treatment. Now if that’s the case, we can produce tons of that quite quickly I would have thought. It’s a very old drug. The Chinese are doing trials on that now. The trials take a few weeks… As far as I know they’re doing proper randomised double-blind controlled trials. It’s very impressive the way they’ve mounted them quickly, and they’re hoping to report those in a few weeks. It should be possible to answer your question in a few weeks. At the moment, there is no evidence base for these remedies. If you take for example the idea of reducing inflammation that could be good because there’s a condition called acute respiratory distress syndrome where the fluid collects in the lungs and that’s caused by inflammation. If you took strong drugs like we do in hospitals to reduce inflammation called steroids, then that will reduce the efficiency of the immune system. It’s actually a very clever doctor that would decide on whether that was appropriate or not. So, the fact that something is anti-inflammatory, it’s not axiomatic that that is going to be beneficial. It could do more harm than good, and we simply don’t have the data to answer those questions.

Looking Ahead

Aside from the immediate concerns, it is essential that national policymakers are thinking through the entire lifespan of the COVID-19 pandemic, including the peak of the pandemic, the post-peak period and the post-pandemic period.

The World Health Organisation’s 2005 Pandemic Phases model identifies Phase 6 as the pandemic phase “characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5.”

In the post-peak period, “pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave.”

The authors continue, “previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature.”

And then there is the post-pandemic period, where it will be important for governments to maintain surveillance and updated pandemic preparedness and response plans. “An intensive phase of recovery and evaluation may be required.” Governments may well be dealing with extensive social and economic fallout from the pandemic as well at this point.

Dr. Campbell offered his thoughts on dealing the long-term lessons from the COVID-19 pandemic.

What policymakers need to work out is how to facilitate cultural change and social isolation, while still facilitating economic wellbeing. That is the main challenge for policymakers. People still need to make a living, but for a period of time we are going to need social isolation. The other thing that policymakers are going to have to work out is how they are going to treat the proportion of people that are going to get a severe form of this condition, and need medical support without infecting all of our frontline medical and nursing staff. That means a lot of personal protective equipment (PPE) and quite a bit of training, and a lot of resources: drugs, medical equipment, things like oxygen masks. We are probably going to need thousands of them. In my Accident & Emergency department, I don’t know how many we’ve got, we’ve probably got a couple of hundred of them, but probably not a couple of thousand. Longer-term… the Chinese Government have already banned wild animal markets. So, we need to look at the way we interact with nature because these viruses are zoonotic, they come from animals. We need to treat wild animals with respect for this reason as well as any other reason. The other factor that seem to be an issue here is that people that smoke and live in polluted areas, there’s emerging evidence that they don’t do as well. So, we need to look at reducing pollution and atmospheric pollution particularly in our cities. We also really need to start considering the interconnected nature of the world. Is it actually normal for people to fly to a conference in Singapore for three day,s then fly back again? Are there not other ways to do this? Apart from the environmental factors, we have become dependent on this level of interconnectivity, which we’ve only had to the last twenty or thirty years, and yet we seem to have become dependent on it in such a short period of time. I think that needs looked at with a bit of blue sky thinking.

The Flower Fadeth

In the broader picture, human life is both finite and precious, few things brings that into such sharp relief as pandemics. What lessons do pandemics have for us on human mortality and human existence?

I am afraid in my line of work I’ve always realised about the tentative, provisional nature of human life, having seen people die or suffer significant disease at every stage of life. It’s a very interesting question, because throughout human history, there’s always been infectious disease. So, there’s the Biblical plagues… in 1348, the Black Death arrived in our country and killed maybe 50% of the whole population of Europe, you know, we’re not really sure. There were outbreaks of plague all the way after that up until 1665. So, this possibility of death and plague has always been there. In 1918-19, there was the American/Spanish flu which killed 50-100 million people in the world, no one is really quite sure. This idea that you can treat everything is quite a novel idea. Even up until the Second World War. You know, George Orwell died of tuberculosis in 1952. Treating these infectious diseases is actually quite a rare thing, so we’ve actually got quite spoiled, really, thinking we can treat everything. I think if this brings about a bit of humility, realising that we can’t treat everything… that we are vulnerable… that we do need to cooperate… that we do need to think about how we can improve global health… and basically how we orientate the world around ecological and human wellbeing, that would be a good thing. If that increases humility in human beings, that our life does hang by a thread, then that’s probably a good thing. We might not go around acting with such arrogance and complacency in this rather special world that we live in.

Author: David McHutchon

Picture by Michael Schwarzenberger via Pixabay.