Year of COVID: Everything We Thought We Knew Was Wrong

Brenda Goodman, MA

March 11, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

It's been 1 year since the day the World Health Organization declared that a new, fast-spreading coronavirus had caused a pandemic.

"WHO has been assessing this outbreak around the clock, and we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction," Director General Tedros Adhanom Ghebreyesus told reporters listening around the world.

"We have therefore made the assessment that COVID-19 can be characterized as a pandemic," he said. "We have rung the alarm bell loud and clear."

By that time, COVID-19 had been known to the world for little more than 2 months. In the US, we could see it coming, but hadn't yet felt its full impact in our day-to-day lives.

Americans had watched in horror and trepidation as China and other Asian countries grappled with their outbreaks. By March 11, Wuhan, the city where the virus first emerged, was already more than halfway through its nearly 3-month lockdown.

Passengers quarantined aboard the Diamond Princess Cruise Ship had been released to return home.

The focus of the pandemic had shifted to Europe. Italy had just expanded a quarantine of its northern provinces to the entire country. Images and stories of overcrowded hospitals and patients dying for lack of medical equipment reached our TVs and phones.

A nursing home in Kirkland, WA, just outside of Seattle, was in the midst of a large COVID outbreak.

The US had restricted travel from China, and would soon restrict travel from Europe.

The same day the WHO declared a pandemic, then-President Donald Trump addressed the nation from the Oval Office. "The virus will not have a chance against us," he said, "No nation is more prepared or more resilient than the United States."

Today, of course, the US leads the world in COVID-19 cases and deaths.

How did we get this so wrong?

Here's a look at some of the many ways we underestimated the new coronavirus, and what those missteps have cost us.

March 2020: No Need to Panic. The Flu Is Worse

March 2021: It's Worse Than the Flu

The US had a plan for responding to a pandemic. It was built around the flu.

Very few people in public health suspected a coronavirus could be this much of a threat for this long.

"I think we've been very focused on influenza. That's with good reason because of historical precedent and that virus's demonstrated ability to repeatedly cause pandemics and so, you know, I think we as a community did get surprised by it," says Mark Heise, PhD, a professor of genetics at the University of North Carolina at Chapel Hill who studies host-virus interactions.

One of the things that makes influenza so tough to stop is that people begin to shed virus before they show symptoms (sound familiar?). When you don't know you're sick, it's hard to stay away from other people.

In the past, diseases caused by coronaviruses like SARS and MERS, while severe, proved to be manageable. They could be controlled.

"What we saw with these other coronavirus infections, people are not really highly infectious until day 5 or 6 of their illness, and you can identify them, isolate them, and you could really shut down ongoing coronavirus transmission of either SARS or MERS," says Michael Osterholm, PhD, director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota.

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Early on, Osterholm says he realized this new coronavirus wasn't sticking with that script.

"For me this was one of those really humbling moments because I went from 'My worst fear is a flu' to feeling reassured it was a coronavirus to 'Oh my, this is a really bad, different coronavirus' and that was just a period of 25 days," he said.

At the end of February, he published an Op-Ed in The New York Times calling the crisis a pandemic and warning that the virus was spreading through the air, a stance that was decidedly against the grain at the time.

"I think probably more than any other time in my career, the amount of blowback I got was really substantial," he said.

March 2020: Masks Aren't Necessary

March 2021: Consider Wearing Two

On March 9, Fox News reporter Eben Brown asked the CDC's Nancy Messonnier, MD, about the panic that was starting to set in around the US. He said he'd recently seen someone wearing a face mask with canisters on the sides, and asked if she thought it might be a good idea to provide some sobriety to the American public on the risk posed by the new coronavirus.

Messonnier said that while masks were very important for healthcare workers, "We really do not think this is the time for Americans to be going out and getting masks."

Other public health experts echoed those comments.

In a Capitol Hill briefing on March 11, 2020, Lisa Maragakis, MD, senior director of infection prevention at the Johns Hopkins Health System told lawmakers, "This is another area where I think we need a lot of messaging to the general public because we do see a lot of images of people around the world wearing masks in public settings. The current guidance is that is not necessary and in fact may not even really add to protection," she said.

In the midst of trying not to worsen severe supply shortages for healthcare workers, messaging about masks got muddled.

In fact, even at the time, there was good evidence to support the use of face masks. Most Asian countries were already using them.

Jeremy Howard, a research scientist at the University of San Francisco, and a team of volunteers, worked furiously to round it all up to try to convince public health officials and a wary public that masks were important.

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Looking back, Maragakis says, "I think this whole process has been humbling, you know for everyone."

Maragakis says the pandemic response was bound to be messy. We were just learning about a new virus and everyone was trying hard to figure out how to stop it. What made this even more painful, she says, was that people were following every twist and turn so closely.

"In science and medicine, we are used to the kind of ebb and flow of scientific information that you know, it's not always linear," she says, "You sort of find your way by triangulating amongst the different pieces of evidence."

"The whole public was faced with following along with science in a way that, you know, I don't think we usually get that level of scrutiny or attention that everyone is seeing blow-by-blow as scientific knowledge is accumulated in real time," she says.

Still, Osterholm says mixed messages may have cost the US in terms of public support.

"I think it is a really unfortunate situation because we burned a lot of bridges in terms of people wanting to follow or support public health measures," Osterholm says.

March 2020: Asymptomatic Spread Is Rare

March 2021: 40% of New Cases Come From People Without Symptoms

The debate over asymptomatic spread boiled over in June, after Maria Van Kerkhove, PhD, head of WHO's emerging diseases and zoonosis unit, told reporters, "From the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual. It's very rare."

The next day, she clarified that what she meant by asymptomatic was very narrow. She was talking about a person with a COVID-19 infection who never develops symptoms. She said transmission of the virus could be more common among people who are presymptomatic, meaning they will eventually develop symptoms, but haven't yet.

In fact, she was hewing to published WHO guidance.

In a Feb. 1, 2020 situation report, the WHO said, "Asymptomatic infection may be rare, and transmission from an asymptomatic person is very rare with other coronaviruses, as we have seen with Middle East Respiratory Syndrome Coronavirus. Thus transmission from asymptomatic cases is likely not a major driver of transmission."

Evidence from outbreaks on cruise ships, homeless shelters, and church choirs suggested otherwise.

review published in September 2020 in the Annals of Internal Medicine rounded all this up nicely, estimating that 40% to 45% of coronavirus infections may come from people who aren't showing any symptoms.

"I certainly wouldn't have predicted asymptomatic transmission," Heise says. He says this may be a case of people expecting this virus to be just like its older viral sibling. "With SARS-1, the people who transmitted were generally symptomatic."

"We still have a relatively poor understanding of how SARS does a lot of the things that it does, from the nonrespiratory symptoms that we see in inflammatory diseases, to effects on the heart, to neurologic outcomes," Heise says.

"I think it's important to remember, even though it seems like forever for all of us, we're only a year into this outbreak. And so it's going to take us a while to sort through the mechanisms and what's unique about this virus," he says "It has lots of secrets we haven't worked out yet."

March 2020: We Don't Think the Virus Is a Threat to Young People

March 2021: Sadly, No.

In his March 11, 2020 address from the Oval Office, Trump stressed the need to take precautions to protect the most vulnerable, including the elderly and those with underlying health conditions that put them at increased risk from infection.

"Young and healthy people can expect to recover fully and quickly if they should get the virus," he said.

That didn't match what Cleavon Gilman, MD, was seeing every day in the emergency room where he was working in New York. 

"Even in March we were seeing young people who were who were getting sick from the virus having to be intubated and die from it," he said.

Gilman says his 27-year-old cousin, who was trying out for the NFL, was one of them. He began collecting reports of the deaths of younger people and tweeting them to raise awareness.

"That idea that young people are not affected, it promoted places like Florida and Texas from just not having any mask mandates, opening up schools, and now we know it's not true," he says.

Over the summer, adults under 30 accounted for more than 20% of all COVID cases in the US, according to the CDC. More than 12,000 Americans under the age of 45 have now died from COVID-19.

"Looking back a year later. I think that misinformation and disinformation was, you know, another contributing factor to how come there's over 525,000 Americans dead," Gilman said.

March 2020: We Don't Think the Virus Stays in the Air for Long

March 2021: Check Your CO2 Levels and Ventilate Because This Virus Definitely Hangs Around in the Air

In a scientific brief published in March 2020, the WHO cautioned that there was no evidence that the virus was lingering in air and making people sick, though recent experiments suggested that it might be doing just that.

Scientists who study aerosols were dumbfounded.

In a strongly worded letter to the journal Science, Kimberly Prather, PhD, a professor and atmospheric chemist at Scripps Institution of Oceanography, sought to clear the fog. "There is overwhelming evidence that inhalation…represents a major transmission route for coronavirus disease 2019 (COVID-19)" she wrote.

In July, more than 200 scientists signed an open letter to WHO urging the organization to "recognize the potential for airborne spread."

"We are advocating for the use of preventive measures to mitigate this route of airborne transmission," they said.

Airborne transmission made proper ventilation of spaces critical, they said.

As a result, in July, WHO revised its guidance on coronavirus transmission saying the virus could remain aloft in indoor, crowded, and inadequately ventilated spaces like restaurants, gyms, nightclubs and places of worship, to name a few.

People were soon buying CO2 meters as a way to gauge how well their indoor spaces were ventilated.

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That recognition was a major victory, but aerosol scientists still say not enough is being done to mitigate this route of transmission.

More than a year later, schools and workplaces are still using Plexiglas partitions, a precaution that aerosol scientists think does very little to stop transmission, since small particles of the virus can float over and around them.

In a February 2021 letter, they called on the Biden Administration to "take immediate action to protect against this source of exposure."

They're calling for tougher workplace standards, and new standards for face masks that work well enough to stop these tiny particles.

"While COVID-19 infections and deaths have started to decline in recent weeks, they remain at a very high level and, unless strengthened precautionary measures are implemented, the new variants will likely bring an explosion in new infections," the authors wrote.

"We have to be humble when we deal with these viruses"

What we didn't realize on March 11, 2020, was that the catastrophe unfolding in Europe was already here.

The virus had already seeded itself across the country. Scientists later estimated the 500 cases and 19 deaths across 34 states that were known to the CDC at the time of the pandemic declaration were only a fraction of the actual number in this country.

After years of starving our public health system of funding, the US was caught ill-prepared to deal with a disaster on this scale. Though experts agreed the best way to stop the spread of the virus was to test, trace, and isolate infected people, the US did none of that effectively, partly due to lack of political will and adequate resources, partly because public health experts underestimated the virus.

Much of the public health guidance given to the public last year turned out to be incorrect.

"Putting aside rampant disinformation and political interference, the real tragedy was not having any COVID-19 testing for the first 2 months of the US pandemic, which promoted diffuse spread of the virus across the country, and we've never been able to contain it since," said Eric Topol, MD, professor of molecular medicine at Scripps Research and editor-in-chief of Medscape.

"That was the unforgivable mistake…a fatal mistake for thousands of Americans," Topol said.

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Of course, it wasn't all bad.  The development of the vaccines, which happened with unprecedented speed, was a dazzling achievement.

"It's astounding, you know, and it's a testament to the scientific community, the medical community, the regulatory community, the pharmaceutical industry, you know the fact that everybody was able to do this," on such an accelerated timeline and without compromising safety, "was a very happy surprise," Heise says.

Now everyone is hoping we can get them rolled out in time.

"I think it's just a reminder that we have to be very humble when we deal with these viruses. We have, have, to be humble," said Osterholm.

Some experts worry we will pay a price for these missteps now.

As he has watched the new coronavirus variants emerge, he says he's realized we're in a whole new ballgame with COVID now.

"I always give people a disclosure when I talk about these viruses now, that you know, I know less about them now than I probably did 6 months ago. And I think that type of open mind is what's going to help get us through here and envision what the future might look like and what we have to plan for," Osterholm said.

 

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