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Q&A: James Hamblin, MD on Why You’re Likely to Get the Coronavirus

By Jason Freely / a couple of months ago
Q&A: James Hamblin, MD on Why You’re Likely to Get the Coronavirus

BACK IN FEBRUARY, James Hamblin — preventive medicine M.D., published book author, staff writer for The Atlantic — published a story about the COVID-19 outbreak that claimed, right in the headline:

You’re Likely to Get the Coronavirus.

Got your attention yet?

Those words sounded off-putting and extreme two weeks ago — now, they just seem wildly prescient. We caught up with Hamblin on Wednesday morning to learn more about how the story came together, what’s happened since, how he’s dealing with the COVID-19 outbreak in his personal life, and finally, what we can possibly expect in the coming weeks. In the two days between our call and this story’s publication, 5,405 more cases were confirmed.

[Because it’s this is a lengthy read, we’ve got links here for those who want to revisit it: On The Headline, On Preparedness, On What We Don’t Know.]

Futurism: Jim, here’s what the people want to know: As a preventive medicine doctor, lecturer on public health at Yale, and someone who writes about this shit, you’re more sanitary than the rest of us.

James Hamblin: Presumably.

Presumably! So: Let’s presume you already wash your hands as much as the rest of us should, and definitely touch your face less than we do. But as COVID-19 progresses, are you doing anything differently? Whether it’s hyper-increased use of hand sanitizer, or not going out to restaurants and bars? Have you changed anything about your life?

No.

No?

I mean, apart from barely sleeping and just thinking about this constantly.

That tracks.

That’s the only thing that changed for me.

Like everyone else in New York, I go out to restaurants. I go to bars. I get delivery. Service industry workers don’t have the economic security or paid sick leave to call in if they get the sniffles. In the places those people work, there are countless potential transmission points for a virus some people don’t even know they have. Do I need to start thinking about changing my habits dramatically?

[Sighs] I don’t know. This could last quite a while, and we can’t have all our small businesses going out of business, which is happening in China. By force. That’s where the economics could be really, really bad. Especially here in Brooklyn where restaurants operate on razor-thin margins. A small number of people who decide they don’t want to eat out or go to the coffee shop will have a big effect. You don’t have to, or want to, shut down the whole society.

What about, say, getting a haircut? Or whatever it is—

Yeah, I’m not gonna be able to advise on that. If we have shutdowns, hopefully we’ll have some uniformity in guidance. Ideally, with really good tracking and testing, we can get an evidence-based assessment that says, ‘okay, we’ve proven that a two-week citywide recommended stay-at-home is proven to be effective when caseloads have reached this level.’ As it is, I think there’s going to be a lot of guessing games, so I don’t know how evidence-based anyone can really be.

Oh, well, that’s dark.

Well, the World Health Organization is praising China’s response. And yes: if you shut down all travel, cancel all schools, close public transportation, and tell everyone to stay home? Yes, you will have fewer cases. But as with all health issues, what is realistic? And what’s effective? You can’t just be like: ‘Everyone eats only salad all the time, and always sleeps eight hours a night.’ You need to balance it with the way life can actually be, right?

And China, for all their success, is a vastly different culture from ours, especially when it comes to municipal responses. To anything.

As a population, they saw it as a war in a way we just won’t.

We won’t. Which leaves us ill-equipped in so many ways—

We have a much more individualistic approach to health. And that is always ideologically opposed to the way infectious diseases work.

You can’t beat them as an individual.

When you talk about vaccine policy, and you talk about infectious disease, the ideology is just clear that health is not an individual endeavor. We are in this together. Vaccines don’t work unless populations coordinate them.

Gotta be honest: I wanna go get shitfaced tonight, at a bar, with other New Yorkers. Will I die?

I’m still going out to restaurants and bars, but I don’t want to be recommending one way or another to people. Look: I know the answer here is not to close down everything at the same time, because we can’t do what China did. And even they had thousands of deaths.

Asking for a friend: Let’s say I just started dating someone, things are good, we’re four dates in. Brass tacks, here. If COVID-19 becomes endemic, does what constitutes “safe sex” now involve hand sanitizer?

[Exhausted] I… have no idea.

But come on! It’s worth asking, right?

No, no, it is. It falls into a similar level of: If a place is being hit especially hard, and resources are tight, or there are suggestions or a widespread order towards staying at home, yeah, you might not want to go have a lot of new contact with people you don’t normally. But if this is someone you know, well, it would still be a higher-risk scenario than normal.

So basically these people should find each other before everyone infects everyone else, barricade themselves in an apartment with several bottles of Ciroc, a couple bags of coffee, a case of instant ramen, a half-ounce of weed, and wait this thing out?

I mean, maybe? I would wish you the best of luck.

I think what people (or what I’m) looking for more than anything is a way to exert control over this situation. Are there measures past washing one’s hands — using sanitary paper to open and close doors, using tissue to touch a subway pole, and so on — can these things actually mitigate risk?

Even if the effect is small, and it doesn’t affect that many people, what we want to do is slow the spread. So small things across the population might add up, but there’s no guarantees stuff like that will matter.

But they’re certainly better than most people throwing up their hands and saying ‘fuckit, we’ll be germy, it doesn’t matter.’

I think so, yeah. Better in terms of slowing transmission.

On The Headline.

To that end, let’s get into your story. When we saw it drop on February 24, this coronavirus story was not… what it is now. My reflexive reaction was: Holy shit, that headline, no way that’s true, but your story is looking more and more prescient as we continue to learn more about COVID-19 and watch its inexorable spread. The U.S. went from 53 to 260 confirmed cases in thirteen days, even with quarantine efforts. Globally, we went from 80,087 confirmed cases on February 24 to 101,781 on March 6. But I gotta ask: Were you concerned at all about the implications — however true — of publishing a headline like that?

Yeah. We were watching pretty quickly after publication how people were responding to the headline. If it felt like there was panic, or that somehow the story wasn’t clear, then we were going to immediately revisit it. And we also made sure that in the sub-headline, there was a clear temporizing measure.

The sub-headline was: “Most cases are not life-threatening, which is also what makes the virus a historic challenge to contain.”

Right. If you interpret the term “coronavirus” to mean “severe illness,” then yeah, it’s super scary. And that’s how a lot of people were interpreting “coronavirus,” at the time. The story is saying most people are not that sick. But it is a pretty blunt statement, as the fact of the matter.

How was the reaction for you, personally?

Good, mostly. There were a couple people, certainly, who were like ‘that should probably be changed, the headline is too scary for people to handle.’ But nobody assumed people were going to read the headline, read the story, and still think the headline should change. If people were scrolling through their social feeds, and didn’t click, they would potentially be scared, and yeah — I don’t want that, but…

Classic Internet. People: Read past the headline, please. For the love of god.

Yeah, I know. When you’re in the medical profession, being blunt is important. Being factual. But you can’t not say things because you think ‘oh, people can’t handle hearing this.’ I don’t know a more clear way to state that premise, which has panned out in a way that — while not everyone — many, many people who understand what’s happening right now agree that this virus is causing a pandemic that will have serious repercussions.

Right. “Likely” as the operative term there. Not “definitely.” Not “probably.” Not “possibly.” But “likely.” Which was canny. It’s broadly specific, concretely nuanced: “You are likely going to catch the novel coronavirus.”

[Laughs] Yeah, I thought about that one for a while.

How did this story start for you?

As a story about vaccines, with a headline about vaccines. And then I started to report it out.

Famous last words.

I talked to the epidemiologist, and then the vaccine people, who were just, like: ‘No. There’s not gonna be a vaccine for quite a long time.’

Oh, god.

Yeah. I talked to them about how people will be trying to develop the vaccine for years from now, which presumes this isn’t just some isolated little thing. We’re going to be putting all that money into this vaccine.

And so that let me work backwards. Which is when I started asking: How long is this gonna play out? How wide is this going to be? And why? Why is this global coalition trying to build a vaccine around something that’s supposedly just in China (and maybe a couple other countries)?

It became clear that it was a much bigger problem. And wasn’t being covered in that way — yet.

It feels like a true sense of urgency and adult-like seriousness as the situation has called for is only just beginning just now! In March! Months after this started spreading! How do you feel, as a professional journalist and a medical professional, about the way media coverage for this has been handled?

So: I think there was a little bit of bias going in to the COVID-19 story coming from a lot of veteran science journalists who — having covered Ebola and SARS — saw stories get reactions that turned out to be heavily-loaded with racism and general attempts to use the moment to shut down borders, profile foreigners, and so on. The general stance of a lot of people who covered those previous stories was like: No.

‘No,’ as in, no, we won’t give into what this could result in? You think there was a reluctance from journalists to buy into COVID-19’s impact?

There was initial skepticism. To shutting down air travel with China, for example, as a sort of perceived political gesture. But that shutdown seems now to have been a prudent move — social distancing and travel restrictions are the core principle of containment in public health.

How’d you end up on the correct side of this story — one of serious concern — two weeks before much of the rest of the world caught up?

I was in a unique position. I’ve been talking to a lot of people in and around this story for quite a while. I was seeing more uncertainty than I’m used to among the truly smart doctors and scientists, who usually have a clear take on where things are going, and how they should or would likely progress.

And from there?

I was trying to understand, first: What is the disease’s progression? How much is it spreading? And how would people know when to go to a doctor? Then: What is the country’s level of preparedness for this?

And I couldn’t get good answers to all these questions.

And… I still quite can’t.

Uhh.

Right. I started to get worried, and yeah, there’s not a benefit to anyone panicking, but there are people who are not taking this seriously. And that clearly has been from the top-down administrative downplaying of the moment.

On Preparedness.

To say we’ve been in a unique political climate for the last four years would be understating the case, but, gotta say, I didn’t think a self-professed germaphobe who proudly wields fear like a cudgel would be downplaying a potential pandemic. Yet here we are. And the media has largely, until very recently, followed suit.

Again, that was probably from preexisting issues. We’ve been saved from these kinds of things in America — Ebola, MERS, et al — except for influenza. And we have this sort of American exceptionalism, in the sense of thinking our healthcare system is better than it is — when, in fact, we’re very vulnerable.

Is that what worries you the most about what’s happening in America, right now?

I’m concerned about the preparedness of any healthcare system.

How so?

We have market forces which dictate that most hospitals try to operate around 90 percent capacity at all times — because it’s not profitable to have a bunch of empty beds. At times when you have a surge of patients, typically, you can transfer people. If there’s a natural disaster or a big fire or something, we’ll airlift people out of New York or New Jersey to Connecticut, and those hospitals can use their extra capacity to help out.

But when you have something that hits in a bunch of places, all at once, that’s infectious, and you don’t necessarily want to transfer patients and possibly the infection to another hospital beyond capacity?

Yeah, that’s what I’m really worried about. That’s what I’m looking into, now.

Shit.

I’m not saying that’s going to happen! Everyone hopes that’s not going to happen.

But the right approach seems to be (as ever) hope for the best, prepare for the worst.

I don’t think people are panicking and doing anything harmful. I’m not telling you to not leave your house or something. Yet. I mean, there might be moments when we need to. But the Presidential administration and local health departments and hospitals are behind the ball. They’re behind the ball on testing. I’m hoping that everyone is preparing for these surges in a way that will not be wasted.

What Makes This Different.

Let’s get into why COVID-19 is such a distinct threat. My impression is: While not as deadly as other terrifying viruses like SARS or MERS, what makes this one such an insane outlier is simply the way asymptomatic people — people who look completely, totally fine — can be spreading around something with a 1-3 percent morbidity rate totally unbeknownst to them and us. Those other ones, they spread through people who were quite obviously symptomatic, yeah?

Yeah, or they just didn’t spread as well — there are different aerosolization numbers about how much each of these spreads from any given person. And each of these viruses have different infectious windows, and COVID-19 seems to have a long one.

SARS and MERS weren’t so infectious (or as infectious as this) for multiple different reasons. And the people who had them got very sick, and just weren’t out in the community. A virus ideally wants you to be out there spreading it for as long as you can. A virus doesn’t want to have you laid up in bed or are dead. This sort of novel virus happens usually when it’s transferred from animals to humans — it doesn’t make sense for these viruses or for us to work this way. You know, most of the microbes we live with are totally symbiotic and helpful and or neutral. And when something starts to kill us like this, and be as transmissible as it is, it’s just a kind of a perfect storm.

A perfect storm, aided by the fact it’s not getting as much attention from the public as it should.

Well, this isn’t getting the attention it deserves all at once because the fatality rate sticks in people’s minds. You know, as in: ‘Oh, if it’s less than 2 percent, or 1 percent, then my odds personally are pretty good.’

Right. Like Trump said, COVID-19 doesn’t “disintegrate” you, so it’s not as bad. As though being “disintegrated” is somehow the low bar.

Yeah, you’re not bleeding from your eyes, and many of these symptoms are symptoms most people have had before or have been through. But in aggregate, there are hundreds of thousands of deaths every year from the flu. And this looks to be very much its own thing. No one wants to put numbers on this, because they could turn out to be very wrong. But this is a similar creature to that. And we’re working hard to treat and contain it now, and identify it in a way that we just kind of don’t with the flu. People are much more complacent about the flu than we’ve been with this. So there’s hope that they won’t go that far — but it is a virus that has the capacity to.

In its most extreme presentations, what differentiates COVID-19 from something like MERS?

I don’t know if I’m qualified to answer that. There’s a lot of varying information, and things are turning out to be wrong, and a lot of it’s coming from China. And, you know, they initially said it was not transmissible human-to-human. And then they said: ‘Oh, a little bit.’

Got that one wrong.

Yeah. And even the W.H.O. just doubled their fatality rate that they’re reporting basically from less than 2 percent to 3.4 percent. And that is not what I’m hearing from other smart people who think it’s probably much lower, but we just aren’t testing wide enough to know. So, there’s just a lot of variables right now. Exact breakdowns of mild versus severe — mild, moderate, and severe cases. Men versus women. These are all questions we have some idea of, but there’s not enough information yet.

On What We Don’t Know.

So, that hits a nerve. When you read about something like the story about the doctor in Wuhan, the whistleblower, a 33 year-old, dying from a COVID-19 infection, you start to become very, very concerned. Because, correct me if I’m wrong, but a 33 year-old doctor is the profile of an otherwise healthy, not-so-at-risk patient.

Right. And that’s what scares people. That’s what sends people into panic mode, and that’s what happened with H1N1, which was actually one of the lightest flu years we’ve had in recent history. We were getting lots of news alerts about H1N1 because of precisely that. It was taking people who were in the prime of life, and healthy. It’s a fascinating principle in infectious diseases. We get upset when they get people who are not “supposed” to die. When you have an 80 year-old person with chronic pulmonary disease who gets pneumonia, no one is extremely shocked. It’s when the high school quarterback dies, where despite aggressive medical care, and everything was done right, when people start thinking: ‘Oh, wait, that doesn’t seem right.’ And that happened with H1N1. So it doesn’t actually have to kill a lot of healthy young people for there to be quite a great amount of panic.

If two healthy-looking people contract COVID-19, is there any kind of genetic predisposition or will we learn of one that might put one of these people more at risk than the other?

Yeah, I don’t know about that.

So, basically, it’s a crapshoot among healthy people?

I mean, look: The immune system is complex, and reacts in weird ways. There’s lots of different variables that go into any one person’s immune response.

Going out and trying to buy so-called immunity boosters — turmeric, Emergen-C — those things aren’t going to help, right? Not because they’re snake oil, but because it’s a crapshoot, anyway, right?

No. A vaccine would help.

Yeah.

Immune response is a balance. If it’s too strong, you get autoimmune diseases that hurt you. And if you don’t have an immune system, you get killed by the pathogen that’s infecting you. You want a balance of something that’s just accurately identifying what needs to be eradicated from the body, and doing it, and not doing much more. All the symptoms that you’re feeling — runny nose, and fever, and cough — are the body’s immune system trying to eradicate this. You want that stuff to be happening because it means you’re fighting it off. But you could also die from too strong of an immune reaction. The things that you understand to affect your baseline immune system are always going to be in play. Stress, and sleeping, and eating well: Nobody’s suggesting that these are things anyone should be doing uniquely now.

So, in a certain sense, as much as it’s a crapshoot, the same rules apply.

Right. “Vulnerable populations” tend to be more vulnerable to infectious diseases. People who are sleeping comfortably eight hours a night, have childcare, can afford healthy diets all the time, and all these other amenities? Less so. There are a million different reasons that this affects populations of people who aren’t as wealthy, and who have less access to medical care. These are things we’ve got to take seriously. It’s not gonna affect everyone equally.

To that end, for example: But our only surefire options for herd immunity are vaccines (which we don’t have), quarantines, and… that’s it, right? ‘Sounds like we’re fuc—

Well, no. For example: You can get the flu every year, but we don’t, we get it maybe every few years. And same with colds. Once you get it, you probably don’t catch the same cold virus after, so people around you that you haven’t infected don’t get it from you, either. Not everyone will get the coronavirus this time. But then some people might get it in another wave, and then not everyone will get it or transmit it, because some people have already survived it.

Someone explained to me that the problem right now is that this is like a room with a bunch of mousetraps in it, and imagine if you were to throw a ping-pong ball into it.

Whimsical.

You know, they’re gonna snap and go off. But that means that some of them wouldn’t go off next time. And some of the mouse traps would still be loaded. So.

We can’t do that right now. So we just… evolve as the situation evolves?

Yeah, you do. And normally the advice here is to trust your government officials, that the CDC has everything under control. And I’d like to think that’s true. But I’d also like to see more transparency than I have. And that’s what I’m looking at right now. I’m not suggesting some radical conspiracy. But I know that a week ago, the President was on TV telling us they hoped to very soon have the case number down to one or two.

We, uh, clearly know that wasn’t the case.

I knew right away. Like: No! There were certainly many other cases while he was saying it. And it’s completely backwards. We need an administration that’s owning this as though right now, we’re in the phase of: the more cases we find, the better. We’re going to celebrate as the number rises. It means we’re finding the problem.

James Hamblin is a staff writer at The Atlantic, a PhD in preventative health, and the author of “If Our Bodies Could Talk: Operating and Maintaining a Human Body” as well as the forthcoming “Clean: The New Science of Skin and the Beauty of Doing Less” (July 2020). You can follow him on Twitter here.

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