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Wash Your Hands, AgainRupert Beale and Thomas Jones
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LRB Conversations

Wash Your Hands, Again

Rupert Beale and Thomas Jones

Following his piece for the LRB on Covid-19, Rupert Beale talks to Thomas Jones about what the novel coronavirus is, how well countries are dealing with it, and what hopes there are for stopping the contagion. The conversation was recorded on the afternoon of Thursday 12 March, before the government announced that it was moving from ‘contain’ to ‘delay’.

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Further reading in the the LRB:

Rupert Beale: Wash Your Hands

Wang Xiuying: The Word from Wuhan

Transcript

Thomas Jones: [00:00] Hello, and welcome to the London Review of Books podcast. My name is Thomas Jones, and today I’m talking to Rupert Beale, who's a clinician scientist group leader at the Francis Crick Institute. Rupert’s written in the latest issue of the LRB about the novel coronavirus. And we’re talking on the phone rather than together in the studio or on Skype, because I’m under quarantine in Italy at the moment and Rupert, you also are not at work today, is that right? 

Rupert Beale: [00:23] That’s right. I’ve got a mild upper respiratory tract infection, I suspect not the novel coronavirus, for various reasons. But one has to be cautious about these things.

TJ: [00:35] I’d like to begin, if I may, by reading a few sentences from your piece, and these are probably the three most alarming sentences in it, but let’s begin with them anyway.

In countries where rapid testing and isolation do not happen, the disease will, at its peak, rapidly overwhelm the ability of hospitals to cope and the case fatality rates will be much higher. The global case fatality rate is above 3% at the moment, and if, reasonable worst case scenario, 30 to 70% of the 7.8 billion people on earth are infected, that means between 70 and 165 million deaths. It would be the worst disaster in human history in terms of total lives lost.

Now you wrote that a week ago, as now we’re recording on the afternoon of Thursday 12 March. Are you feeling more or less optimistic about our chances of avoiding 100 million deaths?

RB: [01:25] Well, I think I’ve very carefully caveated that in the sentence immediately after, by suggesting that everybody expects that people will comply with reasonable public health measures put in by competent authorities. So I don’t think anyone’s quite expecting it to be on that scale. And there are reasons to believe that we are likely to get on top of this virus at some point in the future. So I don’t personally expect it to be that bad. It’s important to have a sense of the scale of it, because if everyone really did operate on a business as usual basis, then I think that would be a reasonable expectation about the global burden of deaths over time. Now I think even the United States and Iran are not quite in that bracket  at the present time, but it shows that this is something that really needs to be taken extremely seriously, and that is becoming abundantly clear. Am I more or less optimistic? I think that the piece so far is holding up quite well in terms of the predictions that you might make from it. At the present time countries such as South Korea, which is an example I mentioned – I could also have mentioned Singapore, Hong Kong, Taiwan, and obviously at least in the later phases when they really knew what they were dealing with, China – have all successfully reduced the number of new cases to very small numbers, in some cases single digits, and you’re talking about quite large populations. There are all sorts of unknowns. So one great unknown is what will happen when the restrictions in those countries are lifted. Will there be a second wave? Will there be potentially a third wave? That’s certainly possible given what we know about the epidemiology of other diseases. The sort of hopeful scenario is that the virus will be quite sensitive to climate and temperature, and in places where it is warmer and dryer, then it will transmit less well. At present, we can’t say that there’s much evidence for that, but that is, as it were, the more optimistic scenario. The sort of more pessimistic end of things is being exhibited in Lombardy where, as you’ll be aware, the healthcare service is under extreme strain, and rationing of ventilatory support is having to be carried out, and that’s resulting in a very high death rate. Now there may be other factors at work in Italy; it may well be that the initial testing and isolation was not carried out efficiently. I think at the moment we’re not sure. But I think what we’re very worried about here in this country, in the UK right now is whether or not our NHS is fully prepared and whether it can cope over the coming weeks and months with what will undoubtedly be a high burden of disease.

TJ: [04:46] Yeah. Because I’ve read somewhere, I think, that the number of intensive care beds per 100,000 population is twice as high in Italy as it is in the UK.

RB: [04:55] I think that may be right per capita for Lombardy. I’m not sure about for Italy as a whole,  that could be the case. You can expand capacity intensive care in terms of machines and beds. The question is, can you expand in terms of staff and other supplies that you might need. So for example one option would be to cancel elective operating procedures, so that gives you access to more ventilators. I expect we will see that. My suspicion is that this will be announced in the near future. That doesn’t get around the problem with not having intensive care physicians and enough intensive care nurses, so there we may be struggling.

TJ: [05:39] And in Lombardy certainly at the minute they’re putting in non specialist doctors to help to the extent that they can.

RB: [05:46] I expect that other physicians and other doctors with some experience will be called in. So for example, people who are experts in respiratory medicine, or usually just practice anesthesia, I expect will be expected to help out when necessary. I think that’s likely to be occurring in the United Kingdom, but we don’t know that. We’re still dealing with a large amount of uncertainty here. 

TJ: [06:12] Simply looking at the shape of the graph of new cases, which appears to be exponential in the UK as it was in Italy, it appears to be following a very similar trajectory to Italy, but 14 days or so behind. Does that seem right or is it again hard to say? 

RB: [06:31]  I wouldn’t like to exactly speculate on that, I’m not myself an epidemiologist. It’s certainly not far off as a prediction. If you try to fit – this would be very naive modelling – if you tried to fit an exact exponential curve in the United Kingdom over the past few days, we were a little bit behind that. In other words, you would have slightly fewer cases than you might naively extrapolate, but that of course is complicated by the way in which testing occurs. So if you test more, of course you will discover more cases and you’re likely to discover more mild cases because patients who are extremely unwell and much more likely to be offered a test, and of course you will never test the entirety of the population all of the time. And we are ramping up the testing capacity. I think in a way, one of the most worrying things I’ve seen, and I hope that people will move to address this very rapidly, is from colleagues who were actually operating these tests that they are essentially under strength in terms of the biomedical support staff they need to operate this. And I don’t think I’m breaking any confidences when I say that we may well be asked, as people who are essentially molecular biologists, colleagues who are essentially just molecular biologists or not biomedical scientists exactly but who can operate the machines effectively, we may well be asked to contribute to that effort. And that, by the way, will be completely appropriate. We’re in a pretty difficult situation here.

TJ: [08:04] So that’s the thing that, as you mentioned earlier, that South Korea is an example who are handling it well, you say, showing what a medium-sized country with a democratic government should do. And they quickly ramped up their testing capacity, educated the public about self-isolation, shut down large gatherings, restricted travel, increased hospital capacity. Do you think that the public in the UK are being adequately educated about self-isolation? 

RB: [08:29] It depends what you mean by adequately. I suspect the answer to that is, in short, no. I think we've got a lot of work to do. Colleagues who are in general practice are, you know – these are anecdotes – are saying that they are still getting patients, for example, who have upper respiratory tract symptoms that come in and essentially don't think that the rules apply to them, sometimes by outright lying to the triage, we are seeing cases of people really not understanding what is meant by self-isolate. And I think the government may end up changing its messaging on this because ‘self-isolate’ is the sort of term that clinicians would understand. Stay at home, don’t go out, don't see your friends. That might be a sort of more prosaic way of expressing the same concept. So I think we do have quite a lot of work to do there. It's also important to educate frontline NHS staff. So I think that at present  there's still a lot of work to be done at the front line in terms of accident and emergency, in terms of how you triage patients to make sure that suspected or possible cases are not left with everyone else. This is complicated by the fact that we have very complicated hospital services. One,  you have quite a number of patients who are immunosuppressed. So, for example, I work in kidney medicine, renal medicine, where we have, for example, transplant patients who are immunosuppressed. It’s likely, very likely, I think from the reports coming from colleagues in Italy that these patients will be at higher risk. In a way, we don’t really want these patients to end up in the same sort of space as patients who have potential Covid-19, and at the moment I think hospitals are struggling to make sure that the pathways are correctly implemented so that we don’t get the potential of spreads to staff and within hospitals. So I think we probably have a lot of work to do with the front line of the NHS right now as well.

TJ: [10:51] Yeah, the BBC today had an interview with David Halpin who they said was a government science advisor, I believe he's a psychologist and not an infectious disease expert, and a member of the behavioural insights team, David Cameron’s nudge unit, who said that the plan was to cocoon at-risk groups while herd immunity is achieved in the rest of the population.  Obviously the long-term goal is herd immunity through vaccination and everything, but does that seem sensible to you?

RB: [11:19] I've only seen a clip of that interview. I think at the moment we don't know if herd immunity will be easily achievable because it's not known what the long-term immune response to this virus will be. We know pretty much for certain from the experience in China that there is short-term immunity to the virus. In other words, once you've been infected with the virus and you've recovered, you're unlikely to be infected again within a short time-frame. What's known with other Corona viruses, so many Corona viruses that have been circulating for a long time, which only cause the common cold can, re-infect patients, that is known. So I think it's probably at the moment too early to speculate on whether herd immunity is going to be achievable in the way that you might expect herd immunity to be achieved, for example, with influenza. Obviously the long-term goal, implementation of what we hope would eventually become an effective vaccine would be herd immunity. And of course it is sensible to protect patients that you would predict to be vulnerable. For example, elderly patients, patients with respiratory conditions, patients with cardiac conditions, and patients who are immunosuppressed. Of course, you would wish to protect these groups. But whether or not a strategy of achieving herd immunity is going to be optimal, I think is very much up in the air at the moment. It's really not clear that that's likely to work. 

TJ: [12:57] And let's talk a bit now about the virus itself. I suppose, ‘what is the coronavirus?’ is one way to begin. 

RB: [13:05] Well, in virus speak, in molecular biology speak, we would call it a positive, in a sense, RNA virus. So that means that its genome is RNA rather than DNA. And we call it positive sense because the genome is read in the same orientation as our own RNAs, the RNAs that we use to make proteins.  And that's in contrast to negative sense RNA viruses, for example influenza, where the genome is the opposite orientation, and this has some quite important consequences for the biology of the virus, one of which is that it produces a lot of its proteins in large sort of blobs. And those proteins then need to be chopped up by enzymes, protease enzymes that the virus itself encodes, those proteases can be the target of antiviral drugs.
And this has been achieved successfully, very successfully, I might say, for hepatitis C, it’s one of the important consequences to understanding the, as it were, the molecular biology of the virus. So that's one thing to say about it. The other thing to say, which I mentioned in my piece, this is a very, very large virus, it’s very complicated. And compared with other smaller RNA viruses, the mutation rate is lower. So you wouldn't predict, not that predictions are always 100 per cent accurate, but you wouldn't predict that it would evolve rapidly to sort of resist attempts at vaccination in the way that influenza does. So it would be a reasonable expectation that if we can generate a vaccine, even if it's a vaccine you need to take multiple times to be really effective, we would have a reasonable expectation that we might be able to very substantially inhibit the spread of this virus through a programme of mass vaccination. But we're not there yet. 

TJ: [15:08] No, of course, and developing a vaccine will take minimum a year, two years if it's even possible.

RB: [15:15] Well, if you went through as it were the sort of traditional process of generating a vaccine then a year would be an absolutely unrealistic timescale. Clearly we're in a very different situation to any situation that we've faced as a species for at least a hundred years. So we are in rather uncharted territory, and I think people will be wishing to accelerate vaccine trials by proceeding, for example, where reasonable straight to in human trials. And that's ‘in’ space ‘human’ trials. Rather than testing on animal models first, which would be a traditional way of doing this. This comes with its own risks, but one has to balance risk against benefit here. So if we are exceptionally lucky, then we'll have a vaccine, which is useful in a year or slightly more. But I think we have to be very lucky for that to be realistic.

TJ: [16:17] In terms of these new so-called novel coronaviruses like SARS and MERS, presumably people began working on a SARS vaccine in 2003. What would have happened to that work and would that work be useful now?

RB: [16:34] The work that's been done on SARS has been extremely useful in an awful lot of ways. So first of all, at a public health level, it's notable that those countries which had experience of the original SARS outbreak, I suspect had been much better prepared for something like this to happen subsequently. And there's more awareness, I think, in those countries, in the public that you're dealing with something, which is potentially much, much more dangerous than a standard seasonal influenza. So that's sort of one aspect of it. We understand a lot about the biology of the virus, because of understanding SARS. Because SARS sort of came and went, there was never the opportunity to develop an effective vaccine, which would have been proven to work. What there was, was the ability for virologists to understand the virus better. And we have what it will reverse genetic systems, quite difficult to use, but you can manipulate these kinds of viruses now, which may help, both with working out things like the pathogenesis of the virus, and also with sort of understanding how you might develop vaccines. So the other thing to say is that there has been some remarkably rapid progress in understanding some of the molecular details of the virus. So there's already a structure, for example, of the main viral protein that it uses to enter cells. You'll have seen the reports from Google Deepmind, whether you've used their protein folding prediction algorithms to give us a reasonable idea of what a lot of the other proteins in the virus looked like. And that will be helpful further down the line for people to look at, at potential antiviral drugs and for people looking at developing antibodies to different parts of the virus, which may give us a handle on the right sort of strategies for vaccination. So we do have a lot of tools that were developed partly in response to the original sort of SARS outbreak. But the amount of funding  of course is limited. And SARS came and went, and a lot of people didn't continue to work on it.

TJ: [19:05] But presumably the funding is available now.

RB: [19:08] It will be. To give, perhaps, listeners an idea of these things, we want to be working with the virus now. But the number one thing of course you need to ensure is safety, so you can't just walk into the laboratory and open a vial of it. That would be completely crazy.

TJ: [19:26] We open a dirty tissue and say here we go.

RB: [19:28] Well, indeed, you have to have proper biological containment facilities, which fortunately we do have in the Crick Institute, but then of course you need to train people adequately. People need to know exactly what they're doing. People need to be able to manipulate and to work with less pathogenic viruses first, and then move, when you're confident that you're doing everything in the right way, only then to the more seriously pathogenic viruses. And of course, there aren't at the moment the tools that we'd want to look at this virus, of course, they’ll all be being generated. And so this research is going to take time. And of course, if you're asking people to stop what they're doing and work on something else, well, we all just have lives too. You can't say, well, we're going to give you funding for a year and good luck. Even though you'd like all the results to be generated as soon as possible, you have to put in place already longterm funding for this. And actually that isn't something that I've seen yet from the UK government, it’s something that I hope we will be seeing in the future. Because if you're asking people to stop what they're doing and spend all their time and efforts on this new virus, they have to be confident that in five years’ time, when the world's attention might be somewhere else, they still have a job and they can feed their family, so there are human factors at play here.

TJ: [21:04] And you said in your piece that you're trying to work out which human proteins SARS-CoV-2 needs to replicate. So that does mean you are studying it?

RB: [21:13] We're in the process of setting this up. So like I said, the number one thing is safety. So at the moment, we're training staff to work in the facility. We're making arrangements for the virus to be worked on in a safe way. I should say that this is very much a collaboration between ourselves and scientists at the Roslin Institute in Edinburgh. We're lucky in the sense that we had already a longstanding collaboration on influenza with a colleague who works in intensive care, but particularly looking at infections that arise in intensive care patients and patients that come to intensive care with serious viral infections. So this is very much a collaborative project, and there'll be expertise from both institutes that we bring to bear on this project.  We're in a situation where we ourselves are unsure about the medium term of where this is all going, and we're just trying to do what we can. Our expertise is in cell biology and this particular method for finding targets so that's what we're doing. I wouldn't like to claim it's the most important thing right now to be researching. It's important that you have a whole variety of things being explored.

TJ: [22:34] Presumably you have as many labs as possible researching as many different things as possible, because who's to say where ...

RB: [22:40] That’s right. And like I say, there may be some short term situations where laboratory scientists who would normally be working on something completely different, but simply because they can operate a quantitative PCR machine effectively may be asked to help with the biomedical scientists who are running the tests and so on.

TJ: [23:01] And a PCR machine is what you use for looking at DNA?

RB: [23:06] Well, the RNA of the virus. So, yes, the test is based on detecting the viral genome, and you do this by doing a quantitative PCR, and there are all sorts of quality controls that you put into that to make sure that you're reducing the chance of a false negative or false positive.

TJ: [23:27]  And in terms of the testing that is available now, they've developed new ones, is that right? I was reading that there’s one that they’ve developed in Israel that they’re now building in Rome which is cheaper...

RB: [23:39] So there are other ways of detecting the virus. One thing you can do is you can have an antibody test, which tests for the presence of viral proteins. And the advantage of that is you could have it as more or less point of use. So in other words you would spit on a little stick, a little bit like a pregnancy test, and then there's a blue line or not. It's very likely that such tests would be extremely useful, especially in settings where there's not the availability of these more complicated tests. They're likely to be on the whole a bit less accurate, but it doesn't mean they're not useful, because you could get the information instantly and you could risk stratifying people in a rational way. So there are companies all over the place which are working on this, certainly there's one in the UK that we've been in contact with. And I think these are serious people who have a reasonable chance of making a very useful device. But again, this isn't instant. This is going to be something which takes time and just having the test, well, if the sensitivity and the specificity of the test are not good enough, you can cause more harm than you do good by testing. So you need to make sure that you've got a reasonable degree of sensitivity and specificity before you start rolling such tests out. And that is something which is going intrinsically to take a fair amount of time.

TJ: [25:08] And the tests which have been done at the minute, the total – I did have the number, sorry, I’ve now lost it – the total number of tests that have been carried out in the UK, in terms of how accurate they are and the chance of false positives and false negatives, how accurate is it?

RB: [25:24] The chance of a false positive or false negative does depend upon exactly who it is that you're testing. So for example, if you have someone who has a family member who's known to have the condition, and then they develop a high fever, a sore throat and they start to have a cough, then what we would say is that the prior probability that they have the condition is very high. So in that circumstance a positive test would very strongly confirm that they clearly had the condition. If you just pluck someone from the street who has no symptoms at all, then a positive test would be less predictive. Now that said, from the QPCR tests that are being done, the ones that are being used at the moment, I'm led to believe they are in fact very sensitive and specific. So false positives are quite rare and false negatives are also quite rare. But that doesn't mean to say they couldn't happen. And so you always have to interpret these statistics with a degree of caution. What is clear is that there will be some people who have mild symptoms who do not meet the criteria for testing that do in fact have the condition, and that's, I think at the moment, perhaps one of the main difficulties and dangers that we face.

TJ: [26:43] And one of the important things is that people in that situation, who have mild symptoms need to stay at home, and not see people because even if they're not, we can't test them, partly because we're limited to how many tests you can do and you have to presumably focus ... another reason it's crazy just to pull random people off the streets and test them is because they probably don't have it, and you're wasting the testing capacity on people. So if you have mild symptoms, but you don't qualify for a test, you need to stay at home anyway.

RB: [27:14] That is true. In an ideal world, we would very much like actually to be sampling people who are totally asymptomatic because it would give us a very good idea of how many patients actually do have the condition and are asymptomatic. My understanding is this was done to some extent in China, in Wuhan and other places, and they were not detecting a high number of patients who were truly asymptomatic. So it will be interesting to see if the data holds up in the United Kingdom, but of course, at the moment when you've got limited testing capacity, it's absolutely why you have to focus that on cases where you think it's most likely that someone will have this. My understanding is that the general advice is changing at the moment. And there will be quite strong advice that if you have even mild symptoms, for example just a cough, you will be told to stay at home, i.e. self-isolate, and that would seem to me to be a sensible thing to implement. Probably yesterday or even before. But it looks as though from the news reports that that will be something which is starting to be pushed by the government as of now.

TJ: [28:33] And maybe this isn't a question you feel you can answer, but the situation that we have in Italy now where if you leave your house you have to carry a piece of paper that you've downloaded from the Ministry of the Interior website that you've signed, stating the time you've left the house, your reason for leaving the house, and if the police stop you and you don't have a good reason for being out, in theory, you can face 12 years in jail – though I doubt that will happen to anyone – those conditions, because of the situation in Lombardy. Is that something that we’re likely to see in the UK two weeks from now?

RB: [29:11] I'm not a politician, and that would be a difficult political calculation to make. If such a thing were necessary, then I would advocate that the government do in fact put such 'draconian' measures in place. The alternative of the health care being in this country being completely unable to cope is too horrible to contemplate, actually. If you get to a situation where the healthcare system is totally overwhelmed, then of course, it's not just patients with Covid-19 that will suffer,  it will be absolutely everybody else with any other kind of medical condition as well. And so necessary measures to protect public health in that sense may well need to be enforced in countries such as the United Kingdom. Whether our political class will have the gumption to do that or not I think is a different matter.

TJ: [30:18] Because in Italy in a sense they were only able to do it politically, or that would be their excuse or they didn't do it until after the health system in Lombardy had been overrun, in one part of the country that was already the case. And in another part of Italy where I am, in Umbria, 900,000 people live in the region, and there are 48 total cases. As we are now under quarantine, under lockdown, whatever you call it, it seems very unlikely that it will spread here. So in a sense, those measures are protecting us, but if they had been introduced earlier in Lombardy they would have protected people who have died. So there is a medical argument for introducing those measures sooner before, not to wait until your health service is overrun. But it's not clear if that’s politically possible.

RB: [31:12] There are, but we also don't know how long people will continue to abide by the rules, as it were. One great unknown is what happens after you lift the restrictions. It's very unlikely for all sorts of reasons that without a programme of mass vaccination, we're going to completely eliminate this disease. And of course, as we've discussed, we're a long way away from that possibility of mass vaccination. So if you put in very restrictive measures, fine, you then reduce the number of new cases and eventually they start going down. Then when you release those measures, you then expect that you'll potentially have a second wave of cases. And there may be behavioural aspects to the way in which this happens that mean that people get fatigued and eventually stop complying with strictures put in place by the government. So we don't know. That could play out very differently in different societies. But as I understand from colleagues in places like Hong Kong, they are achieving a sort of equilibrium, where people are going to work, and life is to some extent quite normal, but everyone on public transport is wearing a face mask. There's not a lot of social interaction, people are not going out together after work and so on, but you're not collapsing the economy. And it may be that it would be possible, in fact, I would hope that it would be possible for Western societies to achieve that equilibrium, if you like, in a way which suits them. But of course we're in uncharted territory, so it's very hard to know. In one sense I'm pleased that the government is taking advice from behavioural scientists. It's not just about extrapolating from an exponential curve or not. In another sense, I think they need to be very aware of the deep uncertainties that we have when dealing with this disease. 

TJ: [33:18] So in that sense, there's an element of wait and see. And in the meantime, as your piece is called, we need to wash our hands and not get too close to each other.

RB: [33:31] That's right. There are all sorts of difficult calls about whether or not you close schools, whether or not you shut down sporting events and so on. I think in a way it's possible to overthink these and to try to be too clever. I do have a worry about “clever” interventions based on sorts of patterns of behaviour. We have, as it were, some proven examples of societies that have really got on top of this. And my suggestion would be that we should try to follow those which are proven to work for this specific disease rather than to extrapolate from models that we've made on different diseases such as influenza, where of course it may turn out that the epidemiology is in some important ways quite different from what we've understood from other viruses. So that would be my general advice on this situation, but no doubt the government will be taking advice from experts in epidemiology and other fields at the moment. It is notable, of course, that Chris Witty has very important and genuine expertise in this himself. So I can see there’s a rationale to the current plan for the government. But other rationales are available.

TJ: [35:10] And maybe it's too much to start talking about the United States, but presumably it could be a lot worse there than it is already in some parts of Western Europe or might be because of the things that they ... not having a health service and the testing capacity and all the rest of it.

RB: [35:25] That’s exactly right. So you could argue that the UK government ought to follow different medical and epidemiological advice. Clearly other governments are taking different views. Who knows who's right? We don't know that, any of us who's working at the moment. That's a completely different situation from simply not taking any medical advice at all, which is close to the position that seems to have occurred, at least in the early phase in the United States. The rollout of testing there has been extraordinarily slow, and people have had to estimate the size of the epidemic, for example, in Washington, by looking at subtle mutations in the genomes of viruses that have been isolated from patients. It's quite extraordinary that you would have to do this. How can I put this? It would be a little bit like trying to discover the tube map by using archaeology or something like that. It would be extraordinary. I'm not sure whether that's quite the right analogy to use, but  you're doing something very difficult in order to piece together in a very approximate way something that you ought to have had an immediate handle on straight away.

TJ: [36:56] And presumably something like Trump’s issuing travel bans, no flights to many European countries except the UK and Ireland, given that there's already community spreaders in the United States, treating it as a foreign virus that could come in on planes from Europe is shutting the stable door, isn’t it?

RB: [37:13] You could argue that there shouldn't be flights coming out of Italy, but the fact is there aren't! I think this is posturing, essentially. Of course, at a more local level, there will be competent health authorities, for example New York City and other places that will be doing their best to get a grip on this, but they will be hampered by an amazing failure of the national response, which probably has many factors to it. Not least that funding for the CDC for this was cut some years ago, which is looking like an extremely bad decision right now – cut, I must say, by the Trump administration. So the situation there is pretty bad, and of course, this is just one reason why it's unrealistic to think that the virus is going to be contained until we have an effective vaccine that we can roll out. It's notable  that in Germany they've done a very large amount of testing. At the moment, the case fatality rate is very low. In France they haven't rolled out quite so many tests, and the case fatality rate is much higher. We'll see where we are shortly.

TJ: [38:48] Okay, well, thank you very much.

RB: [38:50] I will actually say one other thing. So we're all learning a lot about this virus and a lot of people who have expertise in virology who are not themselves corona virologists are getting into this right now. I think there's a reluctance from colleagues, and I understand that, to make statements to the media. Because as scientists, we usually feel that we want to be really an absolutely top expert on the particular subject before we make any kind of pronouncement on it. And that I think is absolutely right. In this situation, nobody's really a top expert on this because there just isn't the experience. And the problem is if we collectively as scientists, all sort of wait until we have the fine grain detail of every answer, then what will happen is the airways will be filled up with people who've got no idea what they're talking about. And I think we need to be in a situation where that does not occur. So this is why for my piece, I was extremely careful as far as possible to check with as many colleagues as I could who have experience of the situation in China, the situation in the United States and in the UK, before I was happy with the piece, and I'm very grateful to those colleagues who are coming back so quickly with important and very constructive comments on the piece. And I say this by way of caveat. Obviously I'm talking to you now, I'm not sitting around with five other virologists telling me actually, you've got this right, you've got this wrong, maybe you should have phrased it like that. So we collectively as scientists are dealing with a lot of uncertainty and doing our best to get it right.
I'm speaking not because I think I've got all the answers, but because I think I might at least have some idea of where those answers lie.

TJ: [40:52] Thank you, Rupert, very much.

RB: [40:54] And thank you very much for having me. 

TJ: [40:56] You can read Rupert's piece in the current issue of the LRB, along with Colin Burrow’s review of Hilary Mantel's The Mirror and The Light, Richard Lloyd Perry's Akihito and the Sorrows of Japan, the last of this year's LRB Winter Lectures lectures, Abigail Green on Christopher Clark's Time and Power and James Butler on the BBC.

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