The Science Fiction of COVID-19 | Past, Present and Future Realities

A lot of people feel that we are over the hill, from now on it will become easier. The worst is over. Well, depending on where you are in the world that is. I am Dutch-Australian but living in the UK. I have family, friends and connections all over the world and get to see and hear different experiences.

For everyone the question is what will we do next, what will happen?? How will society and the economy look like?? The short answer is that one day we won’t think of this time again. How soon or long? Well that is a bit more complicated. In fact even the best scientist doesn’t know yet. As I write, the world and science is evolving and we are learning every day of how this disease works and how it impacts us.

Economics and Our Health?

I regard myself as reasonably well-informed individual and although I have a reasonable background in healthcare I have no medical qualifications and am not a scientist or traditional economist. I am a bit of a perfectionist and if I were a scientist I would happily choose to be a mad scientist. I regard myself as socially considerate and am one of those weird pragmatists who also likes to build on dreams. My opinions here may not reflect everyone’s. I did get involved in helping governments with supply chain issues due to COVID-19 and this opened my eyes to what I perceive can or will be the future.

 Although I don’t regard myself as an authority, I did foresee the 1997 Asian Financial Crisis and 2008 Global Financial Crisis. I recognised their impacts on all of us and for example already struggling Greece. I am afraid that my macro-economic views are very different from what is practised and taught at universities but to date I’ve not been proven wrong.

 Why am I talking about economics in a global health crisis? Well, by now we realise that COVID-19 has a huge financial impact on everyone. From the employed who are at risk of losing their jobs and those who may see a reduction in salary, to smaller, larger and multinational companies who may go bankrupt. Ultimately this comes at a cost to most countries. Where previously bankrupt banks were erroneously bailed out, now governments, and thus everyone in the country, ‘really’ needs to consider the economic infrastructure. And with that, the way we live and interact, how we spend our money and earn it. Ultimately a strong economy is able to support a strong health care system and society as a whole.

 Many countries, including the UK, NL and AU, have over time seen a slow erosion of public health care. Outright, part or hidden privatisation of public health care has been an issue for many countries over at least the last twenty to thirty years. For some more so than others. Due to the shift of global economies, due to the impact of austerities following 2008, and in combination with more capitalistic thought, many developed countries find that their (public) health care systems were already under stress prior to COVID-19. Even though the health care systems are better off than in many developing countries they were no longer their former glories. As a result, economics have a huge impact on our health, and this should be recognised. Having set the background a little, I'll come back on economics later.

 Can we learn from the past?

As a minor history aficionado, I believe the past is an important aspect we can learn from. So let’s look at history. Laura Spinney (LS), author of ‘Pale Rider: the Spanish Flu of 1918 and How It Changed The World’ and science journalist explained that “We have had a lot of pandemics in our history. We have had 15 flu pandemics alone in the last 500 years.” Over the centuries we have learned from these epidemics and pandemics. We now live in an age of vaccines and increasing better health. Still, when a new virus, a new pathogen, as COVID-19 comes at us we seemed to have both learned from, and forgotten, the past.

A prime example is how we approach lockdowns these days. Looking at history Laura Spinney concludes that “you get only one proper shot by stemming the tide of cases by going lockdown”. However, where today differs from the past is that “this is pretty much an unprecedented experiment. We have never done a lockdown on this scale before” (JB).

The last lockdowns of any size we saw were during the deadliest pandemic the world has ever seen. The ‘Flu Pandemic of 1918’, or the ‘Spanish Flu’ or ‘Spanish Lady’ as it was called, infected a third of the world and of those 10% died, irrespective of age. Obviously the world was different then. Including a world war with troop movements helping the virus quickly spread around the world. There were ultimately three main waves of the Spanish Flu due to the unprecedented movements of people at the time and the somewhat disjointed efforts to halt it. Still, different? Prior to COVID-19 people were very mobile, airlines were growing, airports expanding and where previously you saw the world in the navy or as a soldier, people were very very mobile. As such, many scientists do compare the 1918 Pandemic to today’s COVID-19, Corona virus.

John Barry (JB), professor at the Tulane University, School of Public Health and Tropical Medicine, author of The Great Influenza (Spanish Flu), stated that “the death estimate was extraordinarily wide from 50 to 150 million people. In today’s population terms that would be 220 to 440 million people”.

The difference with 1918 is that today, in the middle of COVID-19, we are less sure of how many people are infected. Although science is today much stronger many if not most countries don’t have adequate testing facilities to gauge the progress and spread of the disease. It is perhaps easy to look back at historical and well researched facts but we should remember that in 1918 scientists also found themselves battling unknowns. They even had less of an understanding and less scientific capabilities. In fact viruses their composition were unknown in 1918. The term virus comes from the Latin word for poison and the term influenza comes from the Italian word for influence. In the Middle Ages the illness was thought to be under the 'influence' of the stars. Over time health science changed but even though Louis Pasteur and Edward Jenner developed the first vaccines they still did not know that viruses existed. It wasn’t until the 1930’s that the workings of virus particles, especially bacteriophages, were understood. In history “there have been 31 documented influenza pandemics, since the first well-described pandemic of 1580, including three pandemics during the twentieth century (1918, 1957 and 1969)” (LB).

There are other differences, where in 1918 people got Spanish Flu symptoms really quickly today COVID-19 comparatively spreads by stealth. COVID-19 can have an incubation period of up to around 14 days (we think) where the Spanish Flu incubation was half of that and apparently often quicker. Today we can die from COVID-19 but the risk of death seems to be less than in 1918. The Spanish Flu moved really quickly and surprised many. “You could bleed from your eyes and ears, which is pretty terrifying to a lay person. People could die in less than 24 hours. There was every reason to stay by yourself" (JB). As a consequence, many cities locked themselves down. “In the US a lockdown was encouraged; this was done city by city. Schools, restaurants and businesses were closed. Public gatherings were banned. People were told to isolate and quarantine. In some places this lasted for months. New York City didn’t do this. Some cities came out of lockdown only to be hit again. This had a colossal impact to people’s lives” (JB).

In 1918 society was very different. Today we are reasonably well informed on what is happening, this was then very different. There was no internet, TV or radio. There were newspapers and only in big cities international newspapers. The chief enforcer for lockdown and self-isolation was fear and terror. The communal fear was added to by the bloodshed of the First World War. People had a lack of trust in leadership. This was made worse by US government at the time spreading falsehoods to boost its cause. The war saw censorship and a clamp down on free media. As the appalling death rate from influenza in 1918 began to affect both the Allied and Axis forces both sides concealed the problem. Only neutral Spanish press reported the alarming mortality rate; this disease, therefore, became known as the Spanish influenza. In Spain itself it was called the French Flu as they believed to have gotten it from their neighbours. Scientists are today still not sure where the disease originated and the USA, France and Britain were suggested suspects.

With no or not much trust in government, communities saw themselves attacked by a strange disease. As a result, some cities went into lockdown much earlier than others. “There were studies that showed that cities which closed down early did much better" (JB).

Lockdowns and Social/Physical Distancing

These days we have country wide directives on restrictions such as lockdowns or advise on social distancing which rightly so should be called physical distancing. However, even today we see that a disease is rarely stopped by national borders. Maps of France with local/regional different restrictions show that we need to target the disease differently on where it is and spreads. As such while on 09 April Wuhan residents were celebrating the end of their lockdown (Not of the social distancing), the same day Suifenhe City in China bordering Russia went into full lockdown. Borders with Russia were fully closed. Just like in 1918 the disease spreads in waves across lands and borders and the risk is that it will return with such a wave.

To control the spread and the wave(s) of the disease we can learn from 1918’s successes and failures. While over a last couple of months a third of the world’s populations has had some form of restrictions imposed in order to stop the spread of the virus. Many countries react differently to COVID-19 and although we like to compare apples and oranges, we need to realise that differences can be valid. In some places people live close upon each other, in others not (population density). In some cultures people hug, kiss and embrace, in others they don’t normally touch and bow or wai. In some countries people may be poor but more self-sufficient living away from others, in others their income depends on service and leisure industries and thus being close to each other. Countries don’t just differ, so do regions and cities. Of course, we like to compare ourselves and perhaps complain about decisions at home in comparison to elsewhere but such a black and white thinking, and perhaps feeling that the grass is always greener on the other side, is wrong.

How To Stop The Wave(s)?

Like any other disease COVID-19 can be halted or slowed down by isolation, quarantine and social/physical distancing. However, human beings are social animals and we also are often dependent upon each other. And these days there are (too) many of us, yes I am guilty as well and love them all. (Behavioural) Science therefore realises that quarantine or any form of this may help but ultimately we know not to be too surprised by resurgence of the disease. The quick return of the disease into what was previously thought to be a situation under control are called waves.

In 1918 we saw three pandemic waves of the Spanish Flu. Will we now see three COVID-19 waves? Obviously there are big differences, both in how the disease spreads as in our more technologically advanced societies. The short answer is, yes we will likely see waves. How many and the severity no one can predict. Normally the second wave is more severe. Where usually in the first wave the disease originated from one point, in the second wave the disease is likely to originate from several points and thus spread faster and harder. Being surprised is not a great thing. Even knowing there is likely a second wave we may not be properly prepared. Often health resources are worn down or depleted after the first wave.

Solutions are therefore in realising what we may have to deal with next. Everyone is preparing differently. Jerome Kim (JK), Director General, International Vaccine Institute, Seoul explains South Korea's "top priority is to make sure the health services are geared up to cope with the second wave of infections. That means that you have your Doctors and Nurses need to be rested, there have to be supplies available, gloves, masks, all the things that care providers need to take care of infected patients. You stock up again on (test) kits you are ready you can handle surge capacity in case there is a huge cluster of new cases. The disease won’t just evaporate, there could be several repeat outbreaks or flare ups."

As such we see China restricting the export of the better FFP3 masks which they are stockpiling. Unfortunately, due to the macro economics and capitalistic thinking of the last 30 years or so we now find that most factories of PPE (Personal Protective Equipment) are based in China, luckily not all. Although masks (PPE) are very important resources to stop and slow down the spread of the disease, to safeguard health care staff and public alike, by itself it is just one of the tools in the toolbox.

The Holy Grail to COVID-19

Yes, the holy grail everyone is looking for can be found here. Governments and Health Care ministers and authorities, and the public, should realise that there is no holy grail! There is not one solution. Realise that and you’ve got the holy grail. The most effective way to stop a virus like this is to have a full set of tools and a vaccine in your toolbox. Production and logistics are part of that and unless there is a global distribution of a vaccine for a period of time, we will also need to include other preventative measures. Social/physical distancing is an important aspect which can help. And identifying the spread of the disease and thus being able to target measures is very important. This last has been proven a challenge for many governments. For example in the UK there was a late start with testing and tracing, followed by a quick abortion. The reasons are unclear to me but are likely a combination of economics, supply chain and operationally unpreparedness. Following scientific advice and upon pressures from the healthcare and public this restarted. It took a month but now the testing capabilities are over 100,000 a day. The status of the previous tracing efforts are unclear and following the example of other countries a mobile app is being developed by the NHS.

Testing the Spread

South Korea is hailed on its testing program at the start of the outbreak. Obviously South Korea learned from its own history. Following South Korea's outbreak of the Middle East Respiratory Syndrome (MERS), a different type of Corona virus in 2015, the country learned from its mistakes and successes and this "gave the country a blueprint" (JK). "Korea was ready with the testing which was a remarkable happenstance because it allowed the Korean government to really understand the dimensions of the epidemic" (JK).

Understanding who is sick, carrying asymptomatic or symptomatic, can only be done with tests. While at the start of the outbreak it is reported that tests were not very reliable at about 70% in combination with other efforts these did help Korea to get the outbreak under control. Yes, tests have apparently improved and now it's estimated to have only about 10 to 15% false negatives. That is still a lot of people potentially asymptomatic in our community and therefore it is just one of the tools needed.

In the UK, for the time being testing is still focused on the vulnerable and health care staff. Most, not all, scientists agree that to make a real impact it needs to go public and work in combination with testing, quarantine and lockdown measures. Compared to the Spanish Flu Lockdowns (restrictions) “is going to be a much much slower process which is much more difficult to manage both politically and from an economic standpoint” (JB).

Tracking the People

Part of what Korea is applauded on is combining it's testing with tracking. "When COVID-19 hit South Korea it quickly brought in a tracking system and isolated people who were infected or were exposed to the disease." (JK).

This combined effort allowed South Korea to be more relaxed about lockdown restrictions. "It did enforce quarantining of cases with the use of phone apps. And large scale gatherings were banned. They never closed the restaurants, malls or movie theatres. Some government concert halls were closed. Concerts by Korean Pop groups were voluntarily cancelled as a part of this campaign as people understood, probably from their experience with MERS, what it meant for the government to impose social distancing. So there was a voluntary compliance and when the epidemic was at its height people were doing what they were supposed to do. They in general didn’t congregate, church services went virtual, and when you went to a shopping mall or a very big store like a Tesco there were very few people in it. Parking lots were empty, people really did a great job" (JK).

Other countries start to realise the benefits of a smart phone app tracking system. As such we see in the UK it's National Health Service currently testing its own smart phone app. Where in other countries apps are sometimes made compulsory and can include travel permissions as a sort of passport to be out and about, in the UK it will be a voluntary download (I highly recommend) and be privacy sensitive and linked to NHS testing services.

COVID-19 Vaccine an Unlikely Holy Grail

Vaccines have not always been available everywhere. Yes, in practise a vaccine can actually eradicate a virus. Smallpox was declared as naturally eradicated in 1980 (the US and Russia still have it in labs). The Rinderpest is the only animal disease (not affecting the homo sapiens animals) to be declared eradicated. To eradicate Smallpox and other diseases the WHO started in 1974 to push for global immunisation programs. For this it needs the corporation from all its members and non-members. As such a huge process is made since 1974 when only 5% of the world’s children were protected from the six killer diseases targeted by the immunisation programme. Even with the support and establishment of Gavi in 2000 that figure was in 2017 on average only 86%, with some developing countries reaching more than 95% immunization coverage. Still, anything less than 100% of global coverage over a period of time will be less likely to eradicate a disease.

However, indeed a vaccine will be the most important tool in the box to get COVID-19 under control if not indeed eradicate it. Now, more than ever before we see a global attention which makes it perhaps possible to make things happen. Unfortunately, we don’t yet have a vaccine.

An Urgent Vaccine Development

Annelies Wilder-Smith (AWS) is Professor of Emerging Infectious Diseases at the London School of Hygiene and Tropical Medicine, Professor at the Lee Kong Chian School of Medicine, Singapore and Consultant to the Initiative of Vaccine Research at the WHO. She recently explained some of the challenges that come with developing a new vaccine.

So how long will it take? “All the latest vaccines took 10 years. During this outbreak there is an incredible political will and a lot of money and a lot of interest to speed up the processes. So there is hope there will be a vaccine in 12-18 months” (AWS).

 Robert Grenfell (RG), Director - Health and Biosecurity at CSIRO (Australia’s National Science Agency) explains that "it is a very complex process. As an analogy trying to put a person on mars is about the level of the science we are trying to do here. The speed we are getting to here has not been seen before. We generally say that from beginning to end to get an vaccine from a new agent through can take 10 to 20 years. So this is in fact very very fast and if we can get this out in 18 months it that will be an absolute record. If we can get it out less than that that would be absolute fantastic because of all the lives we’ll actually safe."

 Sarah Cobey (SC), Associate Professor in Ecology & Evolution at the University of Chicago, also stated “I never seen anything this urgent and this coordinated before”. However, everyone needs to realise that most of the vaccines scientists are working on are only in preclinical stage. Part of producing a safe vaccine is ensuring that the immunogenicity is checked, safety and possible side effects are checked, and ultimately that the level of antibodies are satisfactory so that it is an effective vaccine.

 “The degree of scrutiny will be streamlined in the presence of the pandemic. It usually takes years, but we are in different times we are finding us in and everybody is trying to assist in making sure this process works as fast as possible” (RG).

 “This is a novel pathogen and it is not like a new influenza vaccine which we just repurpose or modify an existing platform. We now have to go through all the steps to make sure. We need to from the current human data what are protective levels we need to learn the natural course of this disease, and we are still all learning because it is only hitting us now” (AWS).

The responses from scientists are both promising giving hope, as well as careful showing possible realities of a long and arduous course. One of my favourite expressions very applicable here, ‘where there is a will there is a way’. However, the will involves whole populations and governments. “They are already fast-tracking as fast as they can. We need speed but we should not rush. Because vaccines in the end should also be safe. And we should not rush and give a vaccine to a population of millions of millions of people and to find then out that there may be a safety issue. I think we need a good balance between speed and still being very diligent in every evaluation check” (AWS).

Annelies Wilder Smith explained how previously during the 1976 Swine Flu the US government quickly approved a fast-tracked vaccine however in the rush the clinical trials had a too small sample size. It was rushed out to a huge population but wasn’t safe resulting in a rare complication, the Guillain-Barré Syndrome. Anyone at any age can get the syndrome but it is more prevalent with adults and elderly.

As Dr Rebecca Kreston explained in her 2013 article, while the WHO were cautious “President Gerald Ford’s administration embarked on a zealous campaign to vaccinate every American with brisk efficiency. Within 10 months, nearly 25% of the US population, or 45 million citizens, was vaccinated, but serious problems persisted throughout the process. Due to the urgency of creating new immunizations for a novel virus, the government used an attenuated “live virus” for the vaccine instead of a inactivated or “killed” form, increasing the probability of adverse side effects among susceptible groups of people receiving the vaccination. Furthermore, prominent American scientists and health professionals began questioning the campaign’s large expense and its drain on scarce public health resources.” This episode is attributed to some of American public’s hesitance to embrace vaccinations. People should know that influenzas can trigger the rare Guillain-Barré Syndrome (GBS) as well. Arguably we should therefore not avoid these vaccines. (If concerned contact your GP or Hospital.)

Production and Distribution of a Vaccine

Robert Grenfell explained how Dr Peter Jay Hotez, Director, Center for Vaccine Development, Texas Children's Hospital, gave evidence to the US congress earlier in April '20. "His team had developed a vaccine for SARS1 with public funds that looked like a promising candidate. However, for the later stage human trials the money dried up" (RG). These days it is not unusual to get investment for clinical trials from the pharmaceutical industry. They "get the patent when investing in the clinical trials and later sell it back to the public." "In his evidence to congress he said that in the end the industry is not interested in investing in a vaccine we’ll have to stockpile. No one wants to invest in a product designed not to be used" (RG). It was further explained that since there were no reported cases after 2004 the pharmaceutical industry concluded that SARS was no longer a major threat could earn money from. Although SARS has a very similar genetic code to COVID-19 we will now never know if the potential SARS vaccine could have given us a head start for COVID-19. When in the UK the pharmaceutical giant AstraZeneca recently announced to agree to manufacture and distribute a vaccine being developed by the University of Oxford its shares rose 3%. Vaccitech Ltd joined in the partnership and the partners have agreed to operate on a not-for-profit basis for the duration of the COVID-19 pandemic. Let's see how that pans out. Keep in mind that the moment the WHO declares there is no longer a pandemic there may still be COVID-19 outbreaks in certain regions. The partners have agreed to make a vaccine available and accessible for low and medium income countries. Note that the vaccine is currently in a first clinical trial phase and we don't yet know if it is going to be successful.

Lessons in Communication

What we have learned from amongst others the, not so, Spanish Flu and the US 1976 Swine Flu is how to communicate. “Public health experts know, have known for ages, that the best way to communicate to populations in a situation like this is to be transparent, to repeat your message often and to keep it simple” (LB). Unfortunately, some in government have been caught out on their half-truths and apparent political spin which undermines their messaging. Where New Zealand’s Prime Minister Jacinda Ardern is appreciated as an example for her excellent communication towards the public and no nonsense approach from her and her team it can also be different. Of course to top them all we have President Trump, but let’s not go into those weird ideas on health. It’s unfortunate but some governments who publicly have a mantra which starts with “we follow the science” seem a times to have included economic, political and behavioural science in their decision making.

Protection

When we all just became aware of COVID-19 my family in China sent some funny photos of how to protect ourselves. We laughed at the time, but ultimately I have to sadly conclude they were some of the best inventive ideas I've seen so far. Personal Protective Equipment (PPE) as we call it in health care is a vital tool in combating this or any serious virus. When in 2014-2016 developed countries saw horrendous pictures on their TV with health care workers in full white coveralls or at least wearing masks it seemed far away and alien to many. People in many developed countries couldn't imagine that they would ever find themselves in such a situation, and many still don't. However, even though such protection may not always be 100% effective it certainly reduces changes of passing the virus. Where in some Asian countries we used to see some people wearing masks in public this was unheard of in many Western countries. It was regarded as a cultural difference and by many frowned upon. Obviously health care workers and others on the front line should be protected as best as possible. This includes shoe covers, gloves, gowns, hats, face shields and masks. But what about the general population? In many countries the question quickly arose if it was necessary to wear masks in public. The answers were varied. Unfortunately it seems to me sometimes influenced by availability, economic and logistical issues. My personal opinion matches those of many in health care and is yes!

Communicating and Deciding Masks

Where for example the Dutch and British governments earlier decided to state that masks for the public were not necessary and gave the impression they weren’t useful now we see the same governments carefully changing tack. They should say ‘sorry we were wrong, we meant well as we wanted to save the little supply we had for Health Care workers, but yes masks help safeguarding the public and slowing the spread, we recommend you use it’. However, while healthcare specialists and virologists are mostly saying this, some governments still show a reluctance. Is this to safe political face?

The problem with this is that in countries where masks were traditionally only seen in hospital or at the dentist many people have now incorrectly made up their mind that masks aren’t protecting against the virus. Now that the messaging changes some people suspect financial motives as many suppliers are profiteering on the supplies. Especially in Germany prices to the public (at pharmacies etc) are/were sometimes criminally high. As part of its exit strategy the government of Belgium just relaxed its restrictions on masks for public, but not until Belgium's Federation for Commerce and Services (COMEOS) agreed that retailers will sell at cost with a small profit margin going to charities.

Most countries and their exit strategies have decided to make them compulsory in any public situation or that they are compulsory in transport only and in others they are only advised. Although every country is indeed different on this we have to conclude that the principals of repetitive, clear, simple and truthful messaging is not always applied. A lesson from the Spanish Flu which unfortunately in this case is sometimes forgotten.

Strategies and the Exit Dream

'We are over the hill, we can go out and play soon'. 'Looking forward to going back to work and things returning to normal'. Sentiments we hear from many. However, the exit is not a simple door to pass through. The exit is maybe better compared to a downhill obstacle course for mountain bikers. And at the bottom of the hill we may find another valley rather than 'normal'. In as long as we are at risk of a new outbreak or a second wave we will have difficulty returning to a 'normal'. Unfortunately it is hard to see coordination between countries where it comes to exit strategies. Some Scandinavian countries felt confident to slowly exit while others never really went into a full lockdown. Recently prime minister, Shinzo Abe, extended the state of emergency for Japan.

Earlier Hokkaido province and island in Japan learned its own grim lesson. It initially acted fast and contained an early outbreak of COVID-19 with a quick three week lockdown. But due to pressure from local businesses and a false sense of security in its declining infection rate the governor lifted restrictions. Consequently a second wave of infections hit even harder. Twenty-six days later, the island was forced back into lockdown. Dr. Kiyoshi Nagase, chairman of the Hokkaido Medical Association who helped coordinate the COVID-19 response said "I regret it, we should not have lifted the first state of emergency”. Hokkaido’s story is a sobering reality check for governments across the world as they consider and adjust their exit strategies.

In Hokkaido's case we see how businesses are eager to restart and reopen. I am sure this is no different from anywhere else on the planet. However, looking back at the Spanish Flu of 1918 "a recent study on the economies showed that the cities that kept the closure longer had a much faster and healthier recovery after the pandemic“ (JB).

While Denmark has a sort of adaptive exit strategy, Jens Lundgren (JL), Professor of infectious diseases, Rigshospitalet, Denmark, admits " We are learning as I am sure every country is". Denmark has decided to start with children returning back to school and "then gradually open up other aspects of society but in a very gradual way" (JL) Denmark realises that the number of cases can and are perhaps likely to increase when stopping restrictions. To keep that in check "testing will be an important aspect and that is helpful and is important. But it is really the behavioural changes of the population that is the most important in order to make sure we don’t get an uncontrolled increase" (JL).

The Combined Toolkit

So, let's conclude in short what the combined toolkit should have been, or could be for a potential wave 2, 3 or..???

• Coordination

Local, regional and international coordination. Internationally the WHO was sort of set up for this but only has as much influence and powers as its members give it.

• Economics need to support Health Services

This means proper and relevant funding for normal operations but also preparedness for serious Pandemics. Emergency funding and stock piling. As well as non-commercial funding of medical research and development including in the field of virology. Avoiding privatisation as this creates different priorities than holistic public health care requires.

• Staffing

Sufficient health care staffing, from nurses to GPs and specialists (see above). Supported and rested.

• Protection (PPE)

Stock piling as appropriate. With emergency preparation (business continuity) plans not only relying on traditional supply chains. Diversification of suppliers and factories. Governments to support regional/local production which benefits local economies and also reduces carbon footprint.

• Identification Testing and Tracking

Testing kits to be developed asap. For COVID-19 stockpile those already available and use them for whole population.

Tracking, mobile app or use from the start or asap. Other non-technical solutions to tracking are available.

• Lockdowns (Isolation/Quarantine)

Immediate until situation assessed or identified by testing and tracking to be under control.

• Physical distancing (old term Social Distancing)

Clear restrictions for businesses and public. Regulated or advised depending on assessment of situation. In the case of COVID-19 we can expect continuing physical distancing until vaccination programs.

• Vaccine

To be developed asap. Making use of new and modern (genetic) and traditional methodologies. Ensuring safety before starting vaccination programs. In the case of COVID-19 it is expected to be at least 18 months away, if not longer.

• Exit Strategy

A tool by itself, but only following assessments of all the above indicating a likely clear and safe.

• New normal

Clear communication on risks and how we can function in daily life to avoid these risks. See below.

Back to Normal?

So far we went through a lot of now and then, but how about the future? I guess that the message that it won't be a quick normal for everyone is clear. Some countries/regions have returned or are returning to a normal but are at risk. Others countries/regions are more isolated and for them the normal is close by. Without the fiction the future tells us it will be difficult or even tragic for some. However, it doesn't always have to be that way.

Science Fiction Your Future

Science fiction gives us a combination of a plausible (science) and imagined (fiction) future. It is hard to say what the future will bring and I am certainly no Nostradamus. But let me give it a try. And why not join me!? Your imagination on how we can make changes for the better can become reality. Ever since the first Science Fiction books were written and movies made we came to realise that yesterday's fiction often becomes today's reality. So let's start with the old term of 'social distancing'. From now on we call it 'physical distancing', because we are still very social, albeit mostly from a distance.

The Future in Health Care

Everyone has an Oximeter at home next to their Thermometer. Hospitals will have sufficient space for physical distancing on wards and in public areas. In many countries this will initially require lots of renovations and additional new built hospitals. Wearing masks throughout the hospital is going to be a requirement for visitors as well as staff. Lower grade FFP2 or even FFP1 masks is the norm and FFP3 for restricted Isolation/Quarantine Wards. PPE is produced in newly opened factories in the area helping local economies and reducing carbon footprint. My wife is pleased to hear that in the future nurses will have sufficient qualified and motivated colleagues. Of course their pay is increased and reflective of their skills and importance, and working hours are reduced from 12 or more to a maximum of 8 hours a day. Consultants, specialists and GPs are in abundance and although some of their pay has been reduced they are happy as they also have a maximum 8 hours day. Although private health care has been nationalised patients are treated as customers and have to deal with maximum a one week waiting list. Ambulances carry Swedish Oxygen Respirators and mostly arrive for category 1 calls within 4 minutes if not earlier, all the time. Hospitals are (re)designed with one way traffic routing. Piped oxygen to each bed is the norm with new plant that hasn't been rusted away since 1994 (sorry personal gripe). All hospitals have at least a quarter of their rooms fitted for negative pressure, and another quarter for positive pressure. Theatres are all properly positive pressure but are shielded. All hospitals use High Efficiency Particulate Air (HEPA) filtration throughout their wards and clinical areas. Hospitals mainly run on renewable energies. All medical research is by law restricted to universities and public institutions. Dentistry is fully covered by national health care. Pharmaceutical industry is producing only and have been nationalised or turned into not for profit organisations. Less developed regions in the world receive health care support from the rest of the world. Health insurance companies closed down as public health care is truly first class.

OK, I did explain at the start that I can dream. There certainly will be a lot of challenges to overcome but if we are all frank and honest about this we know where we should be. On the short and interim term we will need to adapt and a lot can be done already.

The Future of Office and Factory Work

For office workers working from home is the norm. Management reduces work pressures and targets, keeping the distractions of children in mind. More staff is employed to compensate and everyone works a three day work week with pay able to support a family. Higher management and executives follow suit and have a half a day (ok ok!) three day work week, at an unfortunately reduced pay able to support their family. Due to initial large unemployment government introduced Universal Basic Income combined with a three day a week work for public good programme (slave labour some say). Less abled people are properly supported. Public listed companies can only have all their employees as shareholders. Factories had to adjust to allow for physical spacing. Work is spread over more shifts. Factories increase their floor space or open at new locations. Prices of goods went up.

The Future in Tourism and Hospitality, Sports and Leisure

On the short term a lot of tourism and hospitality companies went bankrupt. A few like Mediametic (photo right) adapted to new norms in physical distancing. Where this can work in some settings the big challenges were in transport. Air traffic has reduced and new airlines are using new and old technologies such as airships. Suddenly everyone is enjoying more than first class space. Tourists travel less frequent and less far. Due to renewable energies the costs of travel balanced out. Container ships started to take passengers again. Sailing clippers re-emerged into history.

All hotels are required to be able to provide room service. Rooms are enlarged as guests counts are down. Leisure and sports facilities reinvent themselves with smaller classes and support is more individual. Sports and leisure support is combined with general health supervision through GP and other health care. Everyone gets a smart watch with heart rate, activity monitors, etc.

The Future of Our Societies

In some countries/regions it feels as not much changed since before COVID-19. In others we see new public (nationalised) transport which can support physical distancing. Bus drivers are less likely to die than during the COVID-19 pandemic as their screens are now fully sealed and the airflow is independent. Air conditioned busses and trains use HEPA filters. Trains started to use carriages with compartments (and corridors) again. In developed countries factories have returned. People live closer to work, work comes closer to home. Parents return to children and childcare gets a new meaning. Aged care homes are nationalised and integrated into health care. Properly supported. Aged care homes no longer feel like institutions. Following COVID-19 pensioners returned to work to rebuild their local economies. Economies are more self sufficient and have a much reduced carbon footprint. Free market trading has declined since restrictions on some goods by new import duties supporting local production. Costs of some goods have gone up. People buy less luxuries and quality and durability of goods improved.

Our Next Challenge

Besides the potential of a COVID-19 Wave 2 there are other large issues threatening humanity. Economic and environmental issues due to our carbon footprint and use of the (natural) environment. We are already well informed and well aware of the possible implications. However, COVID-19 has shown us an immediate and urgent threat due to an incubation period of up to about 14 days. We quickly saw people dying around us and reacted quickly (for some not quick enough). The disease of climate change is already here and to flatten the curve we need to do something before we get symptomatic. Unfortunately climate change due our own doing has a much longer incubation period before we start becoming symptomatic, seeing effects more drastically. Or is it, note that the WHO estimates that 4.6 million people die each year from causes directly attributable to air pollution.

What COVID-19 has shown us is that we all, people, societies and (most) governments can act quickly and decisively. Due to the COVID-19 lockdowns and travel restrictions China expects about 18% to 25% in carbon reductions for February to mid March. For the whole year of 2020 it is expected that the EU sees a reduction of 9% and the UK about 5% of carbon emissions. As a result the Himalayas are visible from the Punjab for the first time in 30 years. We will only know later if these percentages will be correct or persevere. However, it has shown us all that we can avoid a potential Logan's Run. Yes, we can tackle viruses like COVID-19 and the Environment. Right now is a good time for cities, regions, countries and the world to built on the COVID-19 reductions and change our societies. Build a better and healthier future for our children. I will be doing my part, you can join me.

Stay Safe!