2. The disease

A pandemic concerns a disease or group of diseases. The commonsensical procedure ought to be first to epidemiologically diagnose a significant rise in morbidity and mortality presenting similar symptoms. So a set of similarities must be found between suspected cases. These must then be studied to determine whether it represents a greater prevalence of a known disease or whether there are differences from other health issues whose behaviour are sufficiently known. This demands time given the multitude of diseases, often with overlapping symptoms. Given humankind is so varied, no one follows or shows the same exact pattern from individual to individual. Caution should be exercised, not haste.

Regarding the present alleged pandemic, it appears to have been the other way round. Namely a handful of cases studied medically, whose symptoms as will be seen are hardly differentiable from those of a whole set of known diseases, gave rise to the declaration of a new disease and to epidemiological studies based on computer simulation and no real data, since no pandemic had yet occurred. Hence from the beginning there appears to have been an absence of logic in procedures, though they certainly conform with the more recent definitions of a pandemic given both by WHO and the Dictionary of Epidemiology, which only require respectively one or two cases when it is thought populations lack immunity.[1] They also conform to the spirit of the 2005 revised version of the International Health Regulations signed by 196 countries and of the 2007 CDC’s “Interim Pre-pandemic planning guidance”, legitimizing legally  measures in a pre-pandemic situation, namely any time, as any time is describable as such.[2]

Notwithstanding this illogicality, what led Dr Zhang Jixian, the first doctor to hypothesize that a new disease had emerged,[3] to order CT Scans of an elderly couple who came to the hospital with fever and cough?

The “clinical signs and symptoms” – the only possible indications of a previously unknown disease – given in the paper she later co-authored can indeed all be attributed to pneumonia or to a number of lung conditions, or even to influenza and thus are common. For these are mainly “fever, with a few patients having difficulty in breathing”,[4] even the later added symptom of loss of taste can be due to multiple illnesses, even the common cold.[5] Many seem convinced any loss of taste they may have suffered since last year is unprecedented. Did they in the past ever focus on this particular symptom, or did the current insistence on it make them focus on it?

According to the Mayo Clinic, blood tests and X-rays are among the usual tools used to diagnose pneumonia, a CT scan may be recommended only if it persists longer than “expected”,[6] which was not the case. Besides community acquired pneumonia (CAP), i.e. developed outside the hospital is known to especially affect the over 80s.[7]

CAP is one of the most common infections and a leading cause of death worldwide, the mortality rate of those hospitalized can be above 20%, whereas the death rate among the 41 of the 44 patients hospitalized was only within this range, about 15%.[8] Pneumonia has also long been the commonest infective reason for ICU (intensive care unit) admission, as well as the commonest secondary infection acquired in ICU. In particular this implies that the state of a patient with pneumonia symptoms admitted to ICU may worsen. More generally, lower respiratory tract infection (LRTI), which mainly consists of CAP is “is one of the major global health problems and among the top 10 causes of death worldwide. In 2017, an estimated 0.47 billion people developed LRTI, and 2.56 million people died from it.”[9] Besides, pneumonia is not the only lung disease of high prevalence and severity. At the time and throughout the winter, Chronic Obstructive Pulmonary Disease (COPD), remained the third cause of mortality in China.[10] According to CNN, in June and July 2019, , Wuhan was the site of protests over air quality and rampant pollution.[11]

Several articles imply that Dr Zhang Jixian was worried both husband and wife showed the same symptoms. But is it so unusual for two people, notably elderly people, who have shared the same roof and thus the same lifestyle, the same diet, for decades, especially in polluted conditions?

The level of “PM2.5 (particles less than 2.5 micrometers in diameter) that can penetrate deeply into the lung, irritate and corrode the alveolar wall, and consequently impair lung function”[12] was excessively high in Wuhan in December 2019, varying between 140 and 250 μg/m3, beyond 162 for most of the month, and beyond 150 for most of January 2020.[13] At these levels, it is considered to result in: “Significant aggravation of heart or lung disease and premature mortality in persons with cardiopulmonary disease and the elderly; significant increase in respiratory effects in general population”, a safe level being estimated to be less than 12.[14] In comparison, PM2.5 levels in Beijing for the period remained on the whole far below 100.[15] Air pollution is known to cause both pneumonia and COPD, especially prolonged exposure, and hence predisposing the elderly.

Did Dr Jixian overreact because of her “experience during the 2003 SARS outbreak”[16] and her conviction this had amounted to a highly contagious disease due to viruses jumping species barriers, a thesis highly popularized for a number of years? We will return to the validity of her convictions later.

The chest scans appear to have confirmed her suspicions and to have convinced her superiors. They show “invasive lesions of both lungs”,[17] but the ground glass opacities seen are not markers of any specific disease or pathogenic agent. They are non-specific findings “with a wide aetiology [cause] including infection, chronic interstitial disease and acute alveolar disease.”[18] In other words, the scans do not suggest an unknown disease. The lesions could be due to pneumonia or more generally a known respiratory disease, or to some co-morbidity.

Whatever might be the case, on 31 December 2019, based on the observation of 44 patients in Wuhan, of which 11 were in a severe condition, and 33 stable,[19] “the WHO China Country Office was informed of cases of pneumonia of unknown etiology (unknown cause) detected in Wuhan”.[20] In other words, rather than searching for the causes of an event, known to have occurred and well-described, from the beginning it became the search for the unknown cause of an event, here a disease, whose occurrence had not been ascertained.

Indeed, only once the occurrence of a specific disease has been confirmed can the question of its evolution be investigated and discussed. Then its causes have to be assessed, notably whether it is contagious or the consequence of environmental and living conditions. Apart from adding to the time required to reach reasonable conclusions, its behaviour may vary from year to year, and from place to place, further jeopardizing any characterization of a pandemic. But the occurrence of a novel disease itself was not satisfactorily confirmed.

Even in the best of circumstances, causality is extremely hard to establish given the complexity of natural phenomena.

  1. https://urmieray.com/whats-in-a-name/
  2. https://urmieray.com/final-prepartions/
  3. http://jnm.snmjournals.org/content/61/6/782.full.pdf+html
  4. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext
  5. https://www.healthline.com/health/anosmia#causes
  6. https://www.mayoclinic.org/diseases-conditions/pneumonia/diagnosis-treatment/drc-20354210
  7. https://www.sciencedirect.com/science/article/pii/S0264410X20314286
  8. Ibid.
  9. https://www.sciencedirect.com/science/article/pii/S0264410X20314286
  10. https://www.brookings.edu/blog/future-development/2020/03/23/a-mortality-perspective-on-covid-19-time-location-and-age/
  11. https://edition.cnn.com/2019/07/10/asia/china-wuhan-pollution-problems-intl-hnk/index.html
  12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740125/
  13. https://aqicn.org/city/wuhan/
  14. https://blissair.com/what-is-pm-2-5.htm
  15. https://aqicn.org/city/beijing/
  16. http://jnm.snmjournals.org/content/61/6/782.full.pdf+html
  17. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext
  18. https://radiopaedia.org/articles/ground-glass-opacification-3?lang=gb
  19. Ibid.
  20. https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/