How did this all start?

The basics are relatively clear: the virus came from bats and likely originated in a market in
Wuhan in late Dec. 2019. The slightly more nuanced story is that it’s thought to have
originated in a very specific kind of market: a wet market. These markets specialize in the
sale of exotic meats/wildlife and are unique in that they house/slaughter a hugely diverse
range of species under one roof. This creates the perfect petry dish for virus’ to evolve and
jump between compatible species. It has been theorized that this virus jumped from bats to
pangolins before becoming transmissible to humans - although pangolins are now being
doubted as an intermediary host. These species would not necessarily encounter each
other + humans in nature, making transmission to humans unlikely under regular
circumstances. But in the confines of a small market, with species from across the world,
transmission dynamics change. These markets were also identified as the source of the
initial SARS outbreak back in 2003.

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Why does it have so many names?

The formal clinical name for the virus is SARS-CoV-2 (severe acute respiratory syndrome
coronavirus 2). It belongs to the family of coronavirus' and triggers a disease now widely
known as Covid-19. If we want to be very specific, the virus has already mutated into two
distinct strains known as SARS-CoV-2, S type and L type. The S type is the ancestral strain,
and the L type evolved from the S type. The L type is significantly more prevalent, but the
difference between both strains is still misunderstood.

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What’s everyone concerned about?

The virus combines both a relatively high case fatality rate (currently sitting around 3.7%,
but thought to be trending towards 5.6% as we speak) with a high transmission rate (every
infected person currently passes it on to 2-3 people). Virus’ typically have one but not both
of these features. They are either highly fatal or highly transmissible.

Importantly it also has a long incubation period (5-14days), during which people can
transmit it without knowing they have it. This makes it particularly hard to contain,
because everything is normal until it’s not, and by that time, other people have gotten it
and are repeating the cycle.

As things stand, roughly 15% of cases result in hospitalization. Many of these result in a
viral induced bilateral interstitial pneumonia, which effectively cripples the lungs and
requires patients to be put on oxygen and ventilators.

There’s a limited amount of said ventilators in any given hospital, and these are also
required for surgeries and other conditions at any given time. This is the one of the biggest
concerns. If too many people get infected at once, there literally won’t be sufficient
equipment to keep people breathing. Thus the death rate increases.

Lastly, its high contagion rate puts medical staff at risk. This is problematic in that the
system depends on healthy staff to treat disease. If the infection propagates rapidly
amongst medical workers, not only will we lose critical front line experts to fight the virus,
we will lose experts in charge of numerous other medical conditions.

The combination of the last two points is what people mean when they say it’s likely to
overwhelm the healthcare system if left unchecked.
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Is that what people mean by flattening the curve?

Basically. If too many people get infected too quickly, the medical system literally won’t be
able to cope. There are a limited amount of hospital beds, doctors, ventilators, etc. at any
given time. If infection numbers spike too rapidly, there is no time to adjust the response.

This has started happening in Italy, and it’s not pretty. Italy is now reporting 250+ deaths a
day. To put that in perspective: the country sat at ~400 total deaths a mere week ago.
Hospitals across the country have essentially stopped regularly scheduled programming.
Surgeries are cancelled, specialists have become generalists, retired doctors are getting
called back, etc.

The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care just
released formal guidelines about how doctors are expected to respond. It likens the
situation to wartime triage. Let that sink in: wartime triage.

To put things crudely: doctors are now having to make decisions about who gets to live. I
promise you that this is the last thing any doctor ever wants to be forced to do.

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Is that the biggest risk?

It’s the most imminent one for sure. According to the data available: France, Spain,
Switzerland, Germany and the US are currently sitting where Italy was 10 days ago. And if
the numbers above are any indication: that means the next week is going to be make or
break.

Ventilators are going to become the single most important line between life and death. All
countries should be doing whatever they can to acquire more. Italy has asked the country's
only ventilator manufacturer to quadruple monthly production and has asked the Italian
army to source more. Germany's government just placed an order for 10,000 ventilators
from a local supplier.

On the medium/long term, a sizeable risk is actually genetic mutation. Virus’ are unstable
and mutate by nature. As mentioned above, this has already started happening with SARS-
COV-2. If the virus evolves further, it may mean that the things we’ve learnt about how to
treat and contain it no longer work. It becomes a giant game of cat and mouse.

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What are the symptoms?

The most important symptoms in order of prevalence are fever, dry cough, mucus in the
throat, fatigue and shortness of breath. 89% of all cases report fever. This should be seen
as the leading indicator to track.

In an analysis of discharged patients (survivors and non survivors combined) it was

established that fever and cough are usually present 6 days prior to the onset of shortness
of breath. By the time shortness of breath sets in, things go south rapidly. According to my
own reading of the data: if you start experiencing shortness of breath alongside any other
symptom, get to a hospital. Full stop.

In cases that go south, the shortness of breath is rapidly followed by sepsis,

ARDS/pneumonia, acute cardiac injury and acute kidney injury.
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Does it effect everyone equally?

No. Chances of severe infection are dramatically reduced in people aged 0-60, and the
likelihood of complications goes up substantially after this. This is only accentuated by the
pre-existing presence of heart disease, lung disease, hypertension or diabetes. Reporting
on this is widely distributed so I won’t spend much time here.

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If I’m young and healthy, what should I be concerned about?

Four things: 1) people over sixty 2) acting as a vector of transmission 3) misunderstood

longterm side effects 4) economic damage. Let’s tackle the first two quickly: if you’re
young and healthy your symptoms are likely to be negligible, that said, you’re also likely to
transmit it to a few people for whom it’ll be far worse. This is how we end up with
overwhelmed hospitals.

Point three has been largely neglected in reporting and research to date. The novelty of this
disease means we really don’t understand its long term health impacts. But here’s what we
do know: Bilateral interstitial pneumonia (the condition is causes in severe cases)
habitually results in lung scaring and diminished lung function.

Some very early reports from China are pointing to a 20-30% reduced lung function in
survivors discharged from hospitals. And if we take the 2003 SARS outbreak as an analog:
studies showed chronic widespread musculoskeletal pain, fatigue and disrupted sleep in
survivors. Some studies have also shown viral infections to be triggers for the onset of
certain chronic diseases. The long terms repercussions of SARS-COV-2 are unknown, but
should be considered and studied seriously. Not all survivors will go back to life as normal.

Lastly, the economic ravage caused by the virus will effect everyone - regardless of health
status. People have started losing jobs, contracts and revenue. The stock market is under
inextricable pressure. Government debt loads are skyrocketing (those’ll have to be payed
for through taxes). Businesses are grinding to a halt. The list goes on. If the cascading
effects are not controlled shortly, it’ll have lasting systemic effects that’ll take years to
recover from.

Governments have started to act in the hopes of calming the markets. Measures include
reduced interest rates; which lower the cost of borrowing capital. This is positive short
term, but far from clear long term.

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What do we know about the mechanics of how the virus operates?

The virus has been shown to enter cells using a protein called ACE2 [angiotensin-
converting enzyme 2] and a protein coding gene called TMPRSS2 [Transmembrane Serine
Protease 2]. This protein lies on the surface of cells and the virus binds to it to gain entry
into cells.

ACE2 is expressed in particularly high levels in the lungs and kidneys (and is therefore
unquestionable linked to the lung and kidney damage that results from severe covid-19
infections).

This newfound understanding of the virus’ cellular entry pathway is a hopeful development
in understanding the therapeutic targets useful in the treatment of the disease.
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How close are we to a cure?

Part of the problem is medical (developing drugs is tough) but part of the problem is
legislative (months of testing are required before new drugs can go to market). Serious
testing protocols rightly ensure that we don’t end up with drugs that cause unsolicited
bodily damage in their broader attempt to solve for disease. Considering this, our most
promising near term solution is to repurpose existing drugs that are approved for the
treatment of other viruses in the west.

In light of recent discoveries around how the virus functions, there’s hope that one or more
existing drugs could be reclassified. There’s a lot of trial and error happening on the
treatment front (this is a first for everyone) but we’re far enough into the infection cycle
that ineffective initial treatment regimens are being abandoned.

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Are any existing drugs showing promise?

Short answer: yes.

They fall into two large buckets: drugs that effect the viral material itself and drugs that
act on the the function of the immune system/human cells.

The immune system plays a key role in controlling viral replication, as such it’s natural that
drugs that effect certain inner cell/immune functions would be of use.

The drugs that focus on the virus itself act by either: preventing the synthesis of the viral
RNA, stopping viral replication by targeting critical enzymes, or by blocking the virus from
binding to human cells.

The few that have shown the most promise to date are drugs that were originally designed
for the treatment of diseases such as Ebola, Influenza, HIV and Malaria. Some of these are
now in phase three in vivo trials in China. Results are expected to be published as soon as
early April. Hope is near.

It’s key to remember that these drugs are currently being used to treat the symptoms of the
illness, but none have shown great effectiveness in preventing the disease. This is a
critical nuance. Prevention will largely depend on the rollout of new drugs/vaccines,
engineered specifically around SARS-COV-2’s genetic makeup. This is where the question
of viral mutation becomes key. The less the virus mutates, the quicker preventive solutions
will become available.

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Why are death rates varying dramatically across countries?

There’s a couple factors that help to explain this: 1) variations in the speed and
seriousness of response from country to country 2) variation in treatment regimens from
country to country 3) variations in the age and health of populations.

At the onset, very little was known about the virus, and knowledge was not evenly
distributed. This led countries to respond with very different levels of speed, and widely
different tactics. Entire books will be written about this once it’s over.

But putting speed and response aside, it's important to remember this was a never before
seen virus. Medical professionals were left to experiment with different treatment
regimens, leading to varying clinical outcomes. This impacted death rates across countries
in the early days of the infection.

Lastly, countries have different demographic constitutions. Italy for example has one of the
oldest average populations in the world - making it particularly vulnerable.

It's hard to isolate any of these as the three really work in conjunction.

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Chilling stat:

In the time that it took to write the above (a few hours), 252 deaths were recorded globally,
as tracked by the real time dashboard setup by the Center for Systems Science and
Engineering (CSSE) at Johns Hopkins University.

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Sources: Research papers and data from: Nature, The Lancet, John Hopkins, Cell Research,
WHO, International Journal of Antimicrobial Agents, The New England Journal of Medicine,
BMC Neurology, and many more. All links available to share. DM me if interested.

Big shoutout to all the health workers who are putting their health on the line and working
around the clock. We can’t thank you enough.