17.04.2020

Coronavirus and capitalism

What characterises modern epidemics? Mohsen Shahmanesh places the current crisis in context

Four months into one of the largest pandemic of our time, it might be useful to look at our planet and ask the question: what distinguishes the pandemics that began with the Spanish flu at the turn of the last century and have taken us through HIV, Sars and Mers, Swine and Avian Flu pandemics to today’s Covid-19? How do they differ from previous known epidemics? And what are the prospects?

We share this planet with millions of species. Normally when we think about these species, or address the threat to their diversity, it is about our fear that this or that plant or animal species may join the dodo. Rarely in any discourse about nature is any attention paid to the invisible creatures that share our planet. That is, unless and until one or other of these enters the human chain. Yet the microscopic and sub-microscopic species that come under the categories of bacteria, archaea and viruses - the non-cellular organisms - comprise the largest percentage of the earth’s biomass compared to all the cellular forms of life put together; including all fungi, plants and animals.

Viruses are distinguished not only by their diversity, but because they cannot propagate by themselves and must enter the cells of a host and hijack its reproductive machinery in order to produce copies of themselves. It is thought that every living creature on earth with a cell - from bacteria to fungi, plants and animals - houses at least one virus and this makes viruses, by definition, the most diverse species on earth. Someone calculated that, if you line up the viruses on earth, the chain would extend 200 light-years out into space: ie, way beyond our galaxy!¹

Two characteristics of viruses facilitate epidemics. Viruses have high rates of mutation in their genome, particularly RNA viruses² (such as HIV and the corona viruses). Such random mutations can on occasion enhance their ability to cross species, or alter their virulence or other characteristics. Secondly, some viruses have the ability to exchange genetic material between two different virus strains, creating a new strain with totally different properties (infectivity, virulence, species specificity, etc).

Once the virus enters a new species, it needs to be able to pass to new hosts in order to survive. A successful virus is one that does least harm to the host, giving it time to pass on to another before the first host eliminates it. A perfect example of a successful virus is that causing the common cold, or the HPV which infects almost everyone on this planet, causing warts and cervical cancer, usually a decade or two after infection. HIV too is successful because it does not cause Aids until 8 to 10 years after entering a host - plenty of time to find a new host. On the other end of the spectrum, Ebola, which kills between 50% and 80% of its victims, is clearly unhappy in the human race and its epidemics are easier to contain even in the extremely difficult conditions of sub-Saharan Africa. The largest known Ebola epidemic in West Africa (2014) lasted just over two years and was ultimately contained by a mixture of case finding, isolation and, later, vaccination.

Then and now

There have been major epidemics in the past that have had devastating effects. These occur when a new organism arrives into a group that has no prior immunity. Such were the plague (Black Death) epidemics of the Middle Ages, which killed off up to half the population in Europe, and by severely diminishing the workforce, are thought to have been one of the key elements in the early development of capitalism.³ The plague bacillus is thought to have been introduced into susceptible societies through trade and then spread through overcrowding in towns and villages. The bacillus is probably passed from an infected to an uninfected individual through a rat flea. Local plague epidemics petered out, as survivors developed immunity.

Cholera, another cause of epidemics, has no known animal reservoir and spreads through contaminated water supply, as was beautifully shown when a London doctor, John Snow, identified a tap in Soho in 1854 as the source. Both these infections had bacterial origin and spread in poorer areas.⁴

Examples of past viral epidemics in susceptible populations are yellow fever, which destroyed Napoleon’s army in Sante-Dominigue (today’s Haiti), and killed off over 70% of British forces in the Caribbean. Similarly the introduction of smallpox and probably childhood diseases, such as measles, by the invading Europeans decimated the native population in the Americas and Australia, who had no prior immunity.

All these epidemics, bacterial or viral, had a spread limited by the mobility of the persons, or the animal species, carrying the organism. Thus epidemics in humans reflect social relations. It is the profound changes in social relations under capitalism that underlie the ability of local epidemics to become global in our time.

Modern pandemics are therefore characterised by rapid spread and are almost exclusively viral in origin. The source of these viruses can be either wild or domesticated animals or both.

1. Influenza: perhaps the first modern pandemic was the Spanish flu that followed World War I and killed up to 50 million people worldwide - more than the carnage of the war. It was caused by the H1N1 strain of influenza that exists in humans, swine and birds. Why that particular strain was virulent is not known, but its propagation was enhanced by the enormous population movements in the years after the end of the war, both within Europe and abroad, and globalised partly by the return of soldiers to their country of origin.⁵ For example, in India it killed up to 12-15 million (about 5% of the population) and in Iran up to 22 % of the population died. The hunger and famines which followed the war were a co-factor in the high mortality.

Since then we have had a number of influenza pandemics caused by recombinant viruses from swine and avian influenza: H1N1 (2009 - duck, chicken and pig) that infected two billion people and the highly virulent H5N1 (bird flu), causing an epidemic in 2004, and other smaller global outbreaks in the following years.

2. HIV: this virus originated by the recombination of two monkey viruses and entered the human host some time in the early 20th century. However, it remained confined to small pockets in west Africa until the building of railways and roads and the growth of mining in central and southern Africa attracted migrant labour. As is well known, the virus is transmitted through unprotected sex, blood products and from mother to child. Hence sex and intravenous drug use are the main engines that made it a global pandemic, with nearly 75 million infected persons and over 32 million deaths by the end of 2019.⁶

3. Corona viruses: the best known member of this family is the virus causing the common cold. The first known pandemic by this family of viruses was Severe Adult Respiratory Syndrome (Sars) in 2003. Sars is another recombinant virus in the bat, which then entered humans via an intermediary mammal - probably in a wet market. In such markets wild and domestic animals are sold alive or are slaughtered in a confined space, with humans roaming around. It is a perfect laboratory for cross-species spread. Sars had a mortality of 10% and killed about 800 people before it was brought under control. Its relatively high mortality facilitated case-finding, quarantining and ultimately eradication.

One particular variety, the Middle East Respiratory Syndrome (Mers), first appeared in Saudi Arabia in 2009 and rapidly spread in the Middle East and beyond. The immediate host animal was the camel and its high kill-rate (34%) meant that it was controlled after over 800 deaths.⁷

Covid-19 is far more deadly globally, because paradoxically it is far less deadly to humans, killing between 1% and 4% of infected persons (the true figure is probably nearer 1%). It is a successful virus, able to spread widely across the world, and is here to stay. Viruses closely related to Covid-19 had been already identified in bats before the current epidemic. This one moved from the bat, through an unidentified intermediary, to humans in early December 2019 and rapidly became global.

The occurrence of pandemics is something virologists and clinicians working in global health have long predicted. The particulars of our globalised world that facilitate the spread of such infections can be summarised as increased speed and volume of mobility, massive population movements, crowding together of ever larger numbers congregating in cities, increasing inequality particularly in access to healthcare, and the fragmentation of health delivery in many countries, brought about by neoliberal capitalism. I will discuss some of these.

Global mobility

All epidemics are fuelled by population movement. Among primates, humans are the most mobile. We have been in constant migration ever since we moved across from Africa about 150,000 years ago.

But this mobility has exponentially increased over the last century or so. Modern transport has not only shrunk our planet, but reduced the time it takes to move from place to place to an extraordinary degree, often within the same generation. My father, when aged six, took one week to travel from a city in central Iran to Tehran, during which one person travelling with him died of typhoid. But half a century later my father flew from Tehran to San Francisco in less than 24 hours. Across the world we now have over 5,000 airports, 1.2 million kilometres of rail and over 30 million kilometres of road. Huge numbers travel vast distances for holiday, pilgrimage and work.

According to the International Labour Organisation, there were 164 million migrant workers in December 2018⁸ - a rise of 9% over the preceding five years. These figures do not include internal migrations within states such as China, estimated as 288 million⁹, and India (139 million)¹⁰. Most migrant workers live in crowded conditions, in single-sex hostels and separated from their family. Such environments were highly conducive to the early spread of the HIV epidemic in Africa¹¹ and elsewhere. Refugees form another group of migrant populations and have also vastly increased over the last century.

The massive increase in migrant labour and refugees is one of the main engines of the global spread of such infections as HIV, hepatitis B and C, and others that can remain infectious in an individual for long periods. HIV provides the model for the spread of these chronic viruses. Its progress across the world was facilitated by worker migration, as construction workers or miners, who often lived in crowded dormitories and were serviced by a small group of sex workers. On returning back to their villages, they infected their partners. In other places (Southeast Asia and the countries of the former Soviet bloc and parts of USA) it was the massive spread of intravenous drug abuse that was, and is, the engine of HIV spread. In the remainder of the world the driver was unprotected sex - both between men and men, and men and women. One specific example of the relationship of travel and spread of a virus was the role long-distance truck drivers played in the spread of HIV in Africa and India. The infection rate was highest in villages on the main highways and dropped as you moved further away.¹²

For infections with shorter periods of infectivity we need to look at either very rapid population movements, as occur after wars (eg, Spanish flu) or those that follow the globalisation of production, both to work or as leisure, such as mass tourism, or religion (pilgrimage to holy shrines such as Mecca). Here the speed of transport plays a major role, as in the influenza epidemics - and, of course, the current pandemic of Covid-19.

Here we can see the interrelationship between production, industrialisation of sport and religion, poverty and the spread of infectious agents. What shanty towns, refugee camps, packed factory floors, worker dormitories, crowded markets, football matches, and gatherings in Mecca, St Peter’s Square, church, mosque and synagogue have in common are people in close proximity.

But another form of population density that is often forgotten is that of domestic animals crammed together in factory farms. According to estimates, we currently have one billion cattle, one billion pigs and 20 billion chicken in our planet - equivalent to all domesticated animals over the last 10,000 years put together.¹³ Moreover, they have been progressively concentrated in even bigger farms. In 1967 there were one million pig farms in the USA, which shrank down to 100,000 in 2005.¹⁴ Currently over half of all the meat being cultivated globally is in factory farms.

Such concentration of domestic animals facilitates the movement of viruses between the same species, but also brings larger numbers of animals in close contact with birds and bats, allowing cross-species transmission. Birds are the most mobile of all species, often travelling across continents, while bats have a higher repertoire of viruses than most other mammals. Our global capitalist production, with little attention paid to nature, is the ideal set-up for pandemics like the one we are currently experiencing. It is not surprising that virologists have been setting up a global network of sentinel sites, looking for early warning signs of the next epidemic. It is surprising, however, that, with all the warnings given by the scientific community over the last two or three decades, our world was so unprepared for the Covid-19 pandemic.

Health delivery

The issue of equitable health delivery has become a major issue for the left everywhere. The glaring unpreparedness of vast sections of the health delivery system across the world had been brutally highlighted by Covid-19. The tragedy of the US shines a macabre light on the interaction between poverty and health inequality, where the majority of the deaths are amongst African Americans and other ethnic minorities. Here the total failure of private, selective and absurdly expensive healthcare, coupled with a crippling defunding of public health measures under the aegis of the Centre for Disease Control, has resulted in the worse death rate of any country in the current pandemic.

Elsewhere years of neoliberal privatisation, fragmentation, outsourcing, defunding and simply closing down of government-run health facilities has greatly weakened the health sector’s ability to respond to the epidemics.

In the early 1980s International Monetary Fund-induced structural reforms left the African continent totally naked when faced with the rapid spread of HIV (see M Shahmanesh et al, ‘Aids and globalisation¹⁵). In the UK, the persistent underfunding of the national health service, coupled with the outsourcing of laboratory, radiology and other services, plus large sections of health delivery, the privatisation of increasing sections of social care, and underfunding of bodies involved with public health, to name just a few, are to blame.¹⁶ The utter unpreparedness of the UK, as well as many European countries, to deal with Covid-19 was highlighted by the comparison with Germany and Norway. The tragedy of Iran can be summed up by the argument that the country is now a model for ‘herd immunity’, because little was done to prevent the spread until the epidemic had spread virtually all over the country.¹⁷

Control

Management of the current pandemic is at root no different from the way we ought to manage all other infectious agents. Having identified the mode of spread - in the case of Covid-19, droplets of saliva and contaminated surfaces, where the virus may persist for up to seven days¹⁸ - its vulnerability to soap and high temperatures, and the availability of a relatively reliable test to identify the virus, a rational holding operation should be based on the following:

• Mass testing, identifying infected individuals. Because an unknown but significant number of infected persons have no or minimal symptoms, the wider the testing net, the more infections are discoverable.
• Isolating infected individuals and tracing all the known contacts and isolating them.
• Mass lockdown of all those who are not immediately essential to run society to reduce further spread.
• Preparing in advance for the severely ill patients.
• To pursue this policy two characteristics are essential:
• First, a unified command structure directing policy that speaks with one voice and provides accurate information to the public, as it becomes available. Here the unity of the message is the key.
•  Second, a population that believes and trusts the message. Both are vital in order to achieve compliance.
•  These policies have to be tailored and individualised to particular populations and this introduces a third characteristic: a detailed knowledge of the population, where you are trying to induce a change in behaviour.
• Within the global epidemic there are a number of micro-epidemics, each with their own characteristics. These require community-led responses that allow adapting the multiple simultaneous measures needed (for example, social distancing, case-finding and contact-tracing, and using barriers such as masks) to suit the specific circumstances and contexts in which they are being applied. We are here talking of an urgent need for a fundamental democratising process. Already in many countries a number of people have spontaneously self-organised along these lines.¹⁹
• Instead of pitting economy and health against each other, the economic response can be designed to support the public health response: eg, providing basic income for those who cannot work, social welfare to those who are cocooned or isolated, and even mobilising the huge youth bulge globally to deliver key services, while the elderly and vulnerable populations are socially distanced.
• Coordination between the unified central command and community response helps not just the preparation of health facilities, the availability of personal protective equipment, etc, but also the rapid adaptation of innovations, the mass production and delivery of affordable diagnostics, treatments and vaccines, once they are discovered and are widely available for use.
• Finally this is a global epidemic and requires a global solution. This includes sharing all information in vaccine and drug development. These go against the nature of capitalism, where intellectual property is money and cooperation is anathema. Indeed, the immediate response of governments across the world has been to withdraw into their frontiers, which many sealed well after the bird had flown. The WHO is the logical centre for coordinating the containment strategy, but is currently starved of funds.

The current wave of Covid-19 is almost certainly the first of many.²⁰ Until we have a reliable vaccine, we are in a holding operation, and a vaccine, if one is possible, is at least 18 months hence. This virus is here to stay and the future is not going to be the same as the past.

1. N Wolfe The viral storm London 2011.↩︎

2. The genetic material of viruses are either in the form of DNA (eg, herpes and warts) or RNA (HIV, coronaviruses, etc). The latter need to be converted into DNA inside the host before being able to use the host-cell machinery to reproduce themselves.↩︎

3. The Black Death which devastated England in 1348 during the reign of Edward III was worst in the villages, perhaps because there are more rats there. The ensuing shortage of labour increased the bargaining power of the surviving landless workers. See, for example, Patrick Wyman at theconcourse.deadspin.com/after-the-black-death-europes-economy-surged-1821060986.↩︎

4.  For an interesting discussion on the class basis of cholera see RJ Evans Death in Hamburg: society and politics in the cholera years, 1830–1910 Oxford 1987.↩︎

5. JM Barry The great influenza: the epic story of the greatest plague in history London 2004.↩︎

6. unaids.org/en/resources/fact-sheet.↩︎

7. who.int/emergencies/mers-cov/en.↩︎

8. migrationdataportal.org/themes/labour-migration.↩︎

9. clb.org.hk/content/migrant-workers-and-their-children.↩︎

10. weforum.org/agenda/2017/10/india-has-139-million-internal-migrants-we-must-not-forget-them.↩︎

11. ‘Aids and globalisation’: sti.bmj.com/content/76/3/154.↩︎

12. Ibid.↩︎

13. N Wolfe op cit.↩︎

14. Ibid.↩︎

15. sti.bmj.com/content/76/3/154.↩︎

16. nhsforsale.info/nhs-privatisation-overview-2.↩︎

17. ‘Coronavirus: how Iran could become guinea pig for herd immunity strategy’: middleeasteye.net/opinion/coronavirus-how-iran-could-become-guinea-pig-devastating-herd-immunity-strategy.↩︎

18. Covid-19 lasts longer on smooth surfaces, such as plastic and stainless steel. It is easily inactivated by heat and soap.↩︎

19. For example, doctors in many parts of Iran have self-organised into groups that have been providing services to patients - from renting empty properties for those who cannot self-isolate in the north of the country; to city-wide exchange of information, data and experience between clinical staff in Tehran University-run hospitals; to setting up direct internet access to patients with symptoms in Shiraz, advising them clinically, and regularly following them up by trained nursing staff until they are either better or need admission.↩︎

20. See Covid reports: youtube.com/watch?v=05-jbrHRmrs.↩︎