The unknown known: the SARS past of Covid-19

By Ilana Lowy

A previous encounter with a coronavirus

The Covid -19 pandemic has increased interest in past epidemics. Historians are being invited to speak about bygone plagues, from antiquity to the present.  There is a strong focus on the Spanish Flu of 1918-19, but more recent epidemics such as AIDS and Ebola are also getting attention. Rather surprisingly, the 2003 SARS outbreak has occupied a relatively modest place in these conversations, despite the fact that it was induced by a close relative of the pathogen behind the Covid-19 pandemic, and regardless of important resonances between the two outbreaks.

Until 2003, coronaviruses were seen as relatively harmless human pathogens, responsible for 15 to 30% of common colds. However, in 2003 a previously unknown coronavirus produced an outbreak of a potentially fatal pneumonia in humans. The disease was named Severe Acute Respiratory Syndrome, or SARS, and the coronavirus that induced it was called SARS-CoV. The SARS epidemic lasted 5 months.  It infected 8402 people and killed 774, the majority in mainland China and Hong Kong. Other countries affected by this epidemic were Taiwan and Singapore; there was also a severe hospital-based outbreak in Toronto and a smaller one in Vietnam. The 2003 SARS outbreak produced waves of fear all over the world and generated important economic disruption, but it rapidly ended thanks to energetic isolation measures. The virus made a handful of localized appearances in 2004 but has never been seen since. The advent in 2012, of sporadic outbreaks of a related coronavirus, the Middle East Respiratory Syndrome (MERS), did not lead to outbursts of fear on a global scale. Notwithstanding its higher fatality rate, MERS was perceived mainly as limited to small-scale outbreaks in the Middle East, with a single notable episode in South Korea.

Memory of the SARS epidemic remained alive in Southeast Asia, but elsewhere the fear it generated was rapidly forgotten, as often was the event itself, remembered mainly by the pandemic experts. The successful control of SARS and MERS might have contributed to a low level of worry in early January 2020, when the media reported an outbreak of coronavirus-induced pneumonia in Wuhan, China. The closing of the city of Wuhan on the 23rd of January, extended on the 24th to the main cities of Hubei province and the isolation of this province, might have reinforced the perception of the new epidemic, especially outside Southeast Asia, as an internal Chinese problem. Thanks to such a perception, Donald Trump was able to present the banning, for Chinese (but not US) citizens, of travel from China to the US, issued in late January 2020, as a decisive step that he believed eliminated the danger of the ‘Chinese virus’ in the US.

Scholars will undoubtedly explore in depth the similarities and differences between the SARS and Covid-19 outbreaks. My goal here is much more modes. Relying mainly on published materials and existing analyses, I wish to recall the largely forgotten past of the 2003 SARS epidemic and how its dramatic events still produce their own temporality. In June 2020, views held not only seventeen years ago but even four months ago seem to belong to a distant period, one in which ‘confinement’ had not yet become a household term, and in which it was difficult to imagine a world that suddenly came to a halt. The Covid-19 crisis produced a chasm between ‘before’ and ‘after’, and it transformed the ‘before’ into a foreign country (Poles, 1953). This text proposes a rapid tour through that foreign country.

A world-wide scare

The SARS epidemic started in the Guangdong province in China, probably in late November 2002. At that time, the province had two simultaneous outbreaks: influenza and an atypical pneumonia characterized by small, seemingly unrelated clusters of cases scattered over several municipalities. The first outbreak of this atypical pneumonia might have been contained.  A second outbreak, which included an amplified transmission to health workers, started in early 2003. On February 11th, the Bureau of Health of the city of Guangzhou reported to the press the presence of more than 100 cases of an infectious atypical pneumonia in the city. That same day, the Chinese Ministry of Health officially reported to the WHO 300 cases and five deaths in an outbreak of acute respiratory syndrome in Guangdong. The following day, it reported that the outbreak dated back to November 16th, 2002, that the virus responsible had not yet been isolated, and that the outbreak was now coming under control (Parashar and Anderson, 2004).

In late February and early March 2003, clusters of atypical pneumonia were diagnosed in Hong Kong, Singapore, Vietnam, and Canada. Epidemiological investigations revealed that in each case, the index patient for the cluster had stayed on the ninth floor of a hotel in Hong Kong between February 21 and 22. The likely primary source of these outbreaks was identified as a physician from Guangdong. The risk of transmission of the new disease was greatest among those who stayed in close contact with the patient or were directly involved in their care; transmission to casual contacts was rare. On March 11th, 2003, the WHO issued an alert about the  identification of a new atypical pneumonia in Asia and named it  SARS (Gorbalenya et al., 2003) . The virus originated in all probability in horseshoe bats, and virologists suspected that its intermediary host was a palm civet, an animal sold in Guangdong’s ‘wet markets.’ Immediately after the first alert, the WHO received additional reports about more than 150 cases of atypical pneumonia from six Asian countries and Canada. On March 15th the WHO issued a second and stronger global alert in the form of an emergency travel advisory. The WHO, together with its international partners, then initiated a rapid and intense response to the new global public health emergency (Heymann, 2004; Cyranoski 2017).

Between November 2002, and June 5, 2003, 8402 persons worldwide became infected with SARS, the vast majority in China (5329 infected; 334 deaths), Taiwan (678 infected and 81 deaths), Hong Kong (1748 infected and 283 deaths), Singapore (206 infected and 31 deaths), Vietnam (63 infected and 5 deaths), and, in the sole outbreak outside Asia, Toronto (216 infected and 31deaths). SARS resulted in the deaths of nearly 10% of patients, many of whom sought treatment in some of the most advanced hospitals in the world. 21% of SARS cases were among health care workers. The disease was especially dangerous for older people (the mortality rate among those over 60 was more than 40%). By contrast, the disease was uncommon and mild in children. The efforts to control SARS were centralized by the Global Outbreak Alert and Response Network (GOARN), launched by the WHO in 2000. A GOARN-piloted international network of laboratories facilitated rapid identification of the aetiological agent of the new disease, a coronavirus (SARS-CoV), the sequencing of this agent, and the development of a diagnostic test. On July 5th, 2003, 20 days after the isolation of the last known probable case, the WHO declared that the SARS outbreak was contained (Maki, 2003, Ho 2004).

SARS challenged the political and public health systems of all the affected countries. Control was primarily achieved by traditional sanitary methods. Authorities implemented strict public health measures, including the isolation and quarantining of hundreds of thousands of people, and placed tight restrictions on travel. Such measures were especially draconian in mainland China. Chinese authorities declared large regions as epidemic zones and placed people under collective quarantine in villages or institutions. Other countries introduced more restricted quarantines, coupled with testing of suspicious cases, monitoring all the contacts of these cases and placing them under strict isolation if they developed symptoms. The SARS epidemic caused much suffering, significant mortality, great disruption to social and work activities, and considerable economic losses. Nevertheless, the sacrifice was presented as worthwhile. The swift and decisive – for some, brutal – sanitary interventions not only halted the outbreak but also eliminated the threat of the SARS virus ( Enserink, 2003; Christian et al, 2004, Ahmad et al., 2009).

Two factors dominated SARS epidemiology: the presence of super-spreading individuals or events and hospital infections. Epidemiologists found that the majority of individuals with SARS had not communicated the virus to anyone; however, some patients, described as ‘super-spreaders,’ were especially efficient in transmitting SARS-CoV, especially in favorable circumstances (known as ‘super-spreading events’). The result was a great heterogeneity, or overdisperson, in transmission patterns. During the Singapore epidemic, 103 of the first 201 probable cases were infected by just five people. One flight with a single symptomatic person on board lead to 18 confirmed infections and one death. Another flight with four symptomatic persons on board led to one additional infection (Olsen et al, 2003). Because super-spreaders played a key role in the diffusion of SARS, individual-specific control measures, such as tracing and efficient isolation of all contacts, outperformed population-wide measures such as mass quarantine and sheltering in place. On other hand, since the available diagnostic tests were not able to identify the level of dangerousness of an infected person, epidemiologists had to assume that all individuals with SARS were potential super-spreaders whose presence in a setting that favored the dissemination of the virus could produce a super-spreading event (Lipsitch et al; 2003; Tambyah, 2004; Anderson et al, 2004; Lloyd-Smith et al., 2005; Kwok et al.,2007) .

SARS disappeared in 2004, but in 2012 scientists found that a severe atypical pneumonia first described in Saudi Arabia and named Middle East Respiratory Syndrome (MERS)produced by a previously unknown coronavirus, MERS-CoV. Nearly all MERS clusters were linked directly or indirectly to the Arabian Peninsula. One important exception was a June 2015 outbreak in Seoul, A single ‘super spreader, ’contaminated in the Middle East,  was at the origin of a cluster of 186 confirmed cases and 36 deaths. There were no other known outbreaks of MERS outside the Middle East Osterholm and Olshaker, 2017).

The high price of a public health triumph.

SARS had a negative effect on the economy of South East Asian countries, especially on tourism. It also had a significant although more limited effect on the economy and tourism in Toronto. The economies of most of the affected countries in South Eastern Asia were devastated by the consequences of severe travel restrictions imposed by the WHO. SARS demonstrated that in a closely interconnected and interdependent world a new, poorly understood disease with no vaccine and no effective cure can strongly affect economic growth, trade, tourism, business and industrial performance, political careers and social stability. The rapid spread of illness across national boundaries in South Estern Asia  highlighted the immense cost of a poorly- contained outbreak, made visible by dramatic images of empty airports and cancelled flights (Lam et al, 2003; Heymann, 2004).  SARS outbreaks in hospitals led to important reform of security rules in practically all the countries affected by the SARS epidemics. Hospital administrators usually keen on saving money , were vehemently reminded that their first duty was to develop systems that protected staff and patients, and that failure to do so could be much more costly than the savings they were trying to acheive. By May, 2003, economists estimated that SARS-related losses in South East Asia exceeded $30 billion (Huges, 2004).

The epidemic had other consequences. It favored authoritarian measures such as rigid quarantines in China or the deployment of military forces to assist in contact tracing and enforcement of quarantines in Singapore. It also had significant societal effects: social instability that occurred in the hardest hit areas; loss of jobs by some government officials; closures of hospitals, schools, and borders; widespread public panic ,with its emotional and psychological tolls; and an impact on daily life, expressed by heightened fear of infection (Demmler and Ligon, 2003; Tambyah, 2004).

The summer 2015 MERS outbreak in Seoul revived the memory of the dramatic consequences of the SARS outbreak in Southeast Asia. It was controlled by strict sanitary measures. Health authorities directed that all suspected cases be isolated in hospitals or quarantined at home, and monitored the condition of each affected person,. Altogether, more than 16,000 people were quarantined during that outbreak, including an entire village. The outbreak had far-reaching economic, social, and political effects. The major reason why MERS spread so quickly in Korea, public health experts concluded, was inadequate infection control practices. As a consequence, the MERS outbreak led to important changes in the surveillance of infectious diseases in Korea. South Korea’s success in controlling Covid-19 is directly linked with these changes (Osterholm and Olshaker, 2017, pp. 252-253).

The WHO and SARS: an official success story.

In 2003, the US government took a very different attitude toward global health than it  did in 2020. In spite of the post 9/11 rise in nationalism and the outset of the Iraq war in March, 2003, the US was deeply involved in international health collaborations. The US efforts culminated in the founding, in 2003, of the President’s Emergency Plan for AIDS Relief(PEPFAR) and the US’s large contribution to the Global Fund to Fight AIDS, tuberculosis and malaria. Chinese leaders saw the US’s role as a global health leader as an example to imitate. The SARS epidemic led to deep changes in the structure of public health in China. At first, the Guangzhou epidemic did not lead to widespread changes, but when the WHO issued a global health alert in the aftermath of the widely publicized case of a Guangzhou physician who spread SARS to a dozen guests in a Hong-Kong hotel, China’s central government officially recognized its error and made public the steps it had taken to control SARS. Consequently, the Chinese government was praised by the WHO for its decisive sanitary response. The big lessons that the Chinese government learned from the SARS epidemic were that draconian actions are necessary to control a new virus, that China is particularly good at taking such actions, and that it would be praised by the international community for taking them. Some experts pointed to the high cost of the quarantine measures taken by China and argued that it was possible to control SARS with less drastic means, above all careful monitoring of contacts and placing them under strict isolation. Nevertheless, China’s control of SARS continued to be presented in a very positive light (Ahmad, 2016; Manson, 2016, Manson, 2020).

The SARS episode had a decisive impact on China’s public health system. After the epidemic, the Chinese central government invested an impressive amount of money and effort into the replacement of underfunded local anti-epidemic stations with thousands of ‘Centers for Disease Control and Prevention,’ or CDCs, in explicit reference to the US’s CDC in Atlanta, Georgia. Over the next several years, thousands of young scientists with master’s and PhD degrees were hired at local, provincial, and central government levels to carry out the new CDC’s mission. The Chinese were therefore highly disappointed when, during the epidemic of H1N1 (‘swine influenza’) in 2009, US experts who had condemned China for its inaction at the beginning of the SARS epidemic were unwilling to take the necessary steps to control the H1N1 outbreak. Worse, they felt aggravated that the US allowed this ‘American’ virus (most of the experts believe that H1N1 originated in the Americas) to invade China (Manson 2010; Manson, 2015).

The WHO was presented as the main winner in the successful controlling of SARS. Just as pundits were announcing the death of the UN, SARS suddenly gave one of its branches a renewed energy and respectability. The WHO managed not only to forge an unprecedented degree of cooperation among experts and laboratories scattered across the planet but also to elevate itself to a position of global judge and jury. The process was not entirely friction-free.  For example, the governments of mainland China, Hong Kong, Taiwan, Vietnam, Singapore and Canada were dissatisfied with the WHO’s pronouncements about international travel, and occasionally pleaded to be released from the recommendations of WHO travel advisories. Nevertheless, all these governments finally complied with the recommendations. In 2003, decisions on air traffic, which had very important economic consequences, were not seen as a key site of affirmation of national sovereignty but were instead delegated to an international body; this was seen as an especially telling demonstration of the WHO’s newly acquired power (Lam et al, 2003; Fidler, 2004; Baehr, 2005; Widler-Smith, 2006) .

During the SARS crisis, the WHO was able to exercise an unprecedented degree of authority. Despite not being under any legal obligation to report SARS cases, every state affected by SARS – except, initially, China – reported this information to the WHO early and rapidly. The efforts to control SARS also brought to the fore the role of the Global Public Goods for Health (GPGH) campaign. The GPGH was created to promote a shared production of goods such as antimicrobial drugs, and services such as surveillance. The SARS crisis demonstrated the importance of the GPGH during a global emergency. Although it was a fragile triumph, because it relied on a unique and potentially unstable geopolitical configuration, by 2004, SARS control became one of the key elements in the development described by some authors as the WHO’s impressive comeback in the early 21st century (Galvani, 2004; Fidler, 2004; Brown et al, 2006).

 SARS and the rise of the ‘masked Oriental.’

The SARS epidemic was linked with the rise of massive use of face masks in Southeast Asia. Such use of masks is seen as a typically ‘Asiatic’ attitude, indicative of something essential about the nature of mask-wearing societies, and thus as one more element in the ‘othering’ and racializing of these societies, as is, for example, their habit of eating ‘strange’ and ‘disgusting’ wild animals. Modern anti-epidemic face masks indeed originated in China. They first appeared during the 1911 epidemic of plague in Manchuria, and were propagated by the physician responsible for the control of this epidemic, Dr. Wu Liandeb. Dr. Wu claimed that this plague was not spread by rats but was airborne, and he proved his point by adapting surgeons’ masks as protective devices and ordering Chinese doctors, nurses and sanitary staff to use them. In 1911, newspapers across the world featured photographs of Wu’s masks. Beside their efficacy in reducing infections, these masks became an emblem of China’s status as a modern, scientific nation, able to develop path-breaking medical innovations (Lynteris, 2018).

Face masks were widely adopted during the Spanish influenza pandemic of 1918; they appear in numerous photographs of that pandemic. Later, however, their use in the West gradually declined, and after World War II they were seldom employed outside medical settings. By contrast, in China face masks continued to be used during public-health crises. The 2002-2003 SARS epidemic led to their massive adoption as personal anti-viral protection. The Chinese media initially questioned the effectiveness of masks but rapidly shifted to a ‘better safe than sorry’ attitude. This attitude was adopted by other Southeast Asia countries. More than 90 percent of Hong Kong residents reportedly wore them during the SARS epidemic, and photographs of mask-clad crowds in Asia became iconic images of this epidemic across the globe (Sin, 2016; Lynteris, 2020).

Masks, anthropologists have noted, literally and metaphorically changed the visage of the ‘Oriental’ city. Mask wearing was quickly transformed into an invented tradition, and became an obligatory social ritual. The mask culture, anthropologists and sociologists explained, fosters a mutual obligation and promotes solidarity. Masks became the emblematic symbol of the obligation to protect the wider community, and a highly visible sign of collective action. Failing to put a mask on in a public space increasingly became a sign of irresponsible behavior and a violation of social norms (Baehr, 2005). The light blue surgical masks worn by Asian tourists in Western cities  have been read as a visible sign of otherness, of weakness – why are those people so afraid of microbes? – but also of hidden danger, amplifying the stereotype of ‘inscrutable Orientals’ by the impossibility of reading their facial expressions,, potentially hampering one of the main heritages of SARS- the massive use of face masks as public health measure. 

A loud wake up call.

The SARS epidemic was presented as a loud wake-up call for health authorities worldwide. It made visible the crucial need to carefully plan not only for a surge in hospital and laboratory capacity but also for rapid and decisive implementation of containment steps. It also brought to the fore the power of poorly understood transmissible diseases to incite widespread public anxiety and fear, social unease, economic losses, and unwarranted discrimination. (Demmler and Ligon,  2003; Lam et al., 2003; Parshar and Anderson, 2004; McDonnald et al, 2004, Syed et al, 2010). In its immediate aftermath, few specialists doubted that there was more to come. An Institute of Medicine (IOM) report from March 2004 concluded that with the increase of ecological disruption, the expansion of the world’s population, the boom in travel and trade, and the breakdown of public health in many parts of the world, there was a clear increase of the risk of similar outbreaks. The emergence of SARS was seen as a timely reminder of the need to expect the unexpected and to ensure strong national and global public health partnerships. Effectively addressing future threats, experts stressed, would require an enhanced global infectious disease surveillance, development of rapid diagnostic tests, new therapies, and vaccines, implementation of aggressive evidence-based infection control strategies, effective worldwide communication, and well-coordinated international efforts Enserinck,  2003; Tambyah, 2004;  Hughes, 2004).

In 2003, humanity had a truly fortunate escape. The success of the global effort to contain SARS was possible through a combination of efficient public health interventions and a high dose of luck.  SARS was transmitted by droplets during close to person-to-person contact; it did not spread with the same facility as influenza and other infections that are airborne, and did not reach developing countries where surveillance systems were not sensitive enough to detect its presence before it had widely diffused. It could have been otherwise. SARS-CoV could have become readily transmissible from person to person some days before people became seriously ill with the disease, and/or a much higher proportion of infected people could have become ‘super spreaders.’ The next global outbreak, specialists stressed, might be much worse (Maki, 2003; Anderson et al., 2004;  Weiss and McLean, 2004, Heymann, 2004; Pennington, 2004; Ahmad, 2009).

The theme of an extremely lucky escape is also the conclusion of Karl Taro Greenfeld’s popularized history of the SARS epidemic, The Chinese Syndrome (2006), deliberately modeled on bestselling books about imaginary pandemics such as Richard Preston’s Hot Zone.  In 2003 Greenfeld, at that time the editor of Time Asia, lived in Hong Kong and witnessed first-hand the SARS epidemic there. Hong Kong was, after mainland China, the second most affected site in terms of number of cases and deaths. The city was closed to air traffic for fifty-two days, from mid-March to mid-May, and it lost more than 13,000 jobs and nearly all its tourist income. The SARS episode in Hong-Kong was frightening but relatively short. By late May, life had returned to normal. Greenfeld was persuaded, nevertheless, that this event was a dry run for the next, probably much more dangerous, disease outburst, which in all probability would also come from China: “China was transforming so fast that there were bound to be sociological and biological repercussions. With such vast societal shifts (..) there were dislocations that further tore at nature’s fabric. This was common sense: too many people were living too close together with too many wild animals. Welcome, virus.” (Greenfeld, 2006).

Selective memories.

The past may be a foreign country but, to follow Faulkner, it is not dead: it is even not past (Faulkner, 1951). In Europe and North America, reminiscences of major influenza outbreaks, above all the 1918 Spanish Flu pandemic but also the influenza pandemics of the second half of the 20th century and early 21st century – the Asian influenza (H2N2) of 1957; the Hong Kong influenza (H3N2) of 1968; the Swine influenza (H1N1) of 2009 – shaped understanding of the Covid-19 pandemic. After the Covid-19 outbreak, several Western governments, among them those of France, the UK and the US, were severely criticized for insufficient preparation, in spite of experts’ numerous warnings about a pandemic risk. However, such warnings mainly referred to the risk of a severe influenza pandemic, and as a second possibility, the accidental or intentional spread of a deadly pathogen. These trends are displayed in Bill Gates’ 2015 TED talk. In this talk, which has recently been re-presented as prophetic, Gates mainly speaks about the danger of an influenza-like pandemic, which, he assumes, will affect above all developing countries. Unsurprisingly, only a few among the specific steps he proposes have been relevant to the curbing of Covid-19 (Gates, 2015).

Critics of the severe malfunctioning of pandemic ‘preparedness’ initiatives, revealed by the Covid-19 outbreak, point to a low surge capacity in health systems, shortages of masks and protective gear for hospital workers, insufficient numbers of hospital beds and qualified staff, and problems with supplies of drugs and equipment. All these elements were brought to the fore in the aftermath of the SARS epidemic, and were included in plans for preparing for future outbreaks. In many Western countries these plans, it seems, mainly gathered dust in ministerial closets (Davet and Lhomme, 2020). The gap between theoretical preparednessand real life readiness is illustrated by the classification, in October, 2019, of the US and the UK as the countries best prepared for a pandemic challenge (Cameron et al., 2019). In addition, however, preparedness plans seldom took into account some of the most salient characteristics of the SARS epidemic—characteristics that re-emerged with a vengeance during the Covid-19 pandemic.  These incluce the key role of testing, tracing, and rigorous isolation of infected and potentially infected individuals; the protective effect of generalized use of face masks; the risk of spread of the infection in institutional settings; the importance of super-spreading individuals and super-spreading events (Kucharski and Althaus, 2015; Endo et al., 2020).  They also include massive, country-wide quarantines (today renamed containment), interruption of international and national traffic, and the dramatic economic and social consequences of these measures. During the SARS outbreak, quarantines and interruption of long-range traffic took place nearly exclusively in Southeast Asia, that is, in regions in which regimes are depicted  in Europe and North America as uniformly authoritarian and repressive in spite of their variability, while their inhabitants are presented as people who adhere to a collectivist (for some, sheep-like) mindset, readily accept widespread limitation of their freedom, and follow strange customs such as the generalized use of face masks in public spaces (Eichenberg, 2007; Starvo, 2014).

One of the rare experts who discussed the specific risks of coronaviruses was the biosecurity specialist Michael Osterholm. In his bestselling book, Deadliest Enemy: Our War Against Killer Germs of 2017 (written with Mark Olshaker), Osterholm noted that bats in China carry viruses nearly identical to the SARS virus. It is thus possible, he suggested, that SARS is lurking somewhere in China, ready for the next outbreak; it is also possible that MERS, or a similar virus, will strike again on a much larger scale (Osterholm and Olshaker, 2017, pp. 252-253). Osterholm also reminded his readers that the tools that led to the control of SARS were those humans have employed for hundreds of years, mainly quarantines and isolation. On the other hand, he presented SARS, MERS and Ebola as infections that have a regional importance only. Osterholm assumed, like many other experts, that in all probability a future pandemic would take the form of an especially deadly influenza strain (Osterholm and Olshaker, 2017, pp. 445-446). Moreover, he did not believe initially that Covid-19 would represent a real danger. In early February 2020, shortly after the proclamation of Covid-19 as a Public Health Emergency of International Concern (PHEIC) by the WHO, Osterholm explained that what we were seeing was the emergence of a new coronavirus that could very well become another seasonal pathogen, more disturbing than a cold but less severe than SARS, and that would probably be no more dangerous than seasonal flu (Begley, 2020). And in March 2020, when the global risk of Covid-19 became evident, Osterholm argued that shortages of diagnostic tests were not surprising: “no one planned on the whole world experiencing a health conflagration of this magnitude at once, with the need to test many millions of people at the same time (Osterholm and Olshaker, 2020).”

In spite of their familiarity with SARS, Osterholm and his colleagues continue to rely on influenza to understand Covid-19 (Moore et al., 2020). This seems to be the case with the majority of the experts who model the spread of Covid-19 and the role of herd immunity in this spread. Such models usually do not take into account the great heterogeneity (overdispersion) of  the new coronavirus infections; in hindsigt experts recognized this problem (Pegg, 2020). The supposition that Covid-19 propagates in the same way influenza does, however, may be problematic, because influenza tends to spread in a uniform way in populations, while this is emphatically not the case for Covid-19 (Endo et al, 2020; Flahault, 2020, Barneoud, 2020a;  Barneaud, 2020b; Beach et al., 2020). Epidemiological studies increasingly point to the key importance of  super spreading individuals, super-spreading events, and sites such as nursing homes and hospitals in the diffusion of this pathology (Rosenbaum, 2020; Harding and Campbell, 2020). SARS and not influenza may provide more insights for understanding how Covid-19 spreads.

The Covid-19 pandemic, a shocking and frightening event, stunned practically everybody. Even leading coronavirus experts, such as the German virologist Christian Drosten, were surprised. Drosten conceded that despite his deep knowledge of the threat posed by coronaviruses, the new virus amazed him: “I didn’t think that SARS would come back like this – as a virus that is both deadly and much more transmissible. It is adept at infecting cells of the upper respiratory tract, from which a cough can expel it, and unlike SARS – but like the flu – it can spread before symptoms emerge. That’s pretty astonishing.” (Kupferschmidt, 2020).

Living organisms – or perhaps, when dealing with viruses, natural entities of uncertain status – indeed have a capacity to astonish even the best specialists. Nevertheless, once the initial surprise subsides, it may be helpful to revisit all the aspects of the short but dramatic history of outbreaks of SARS, the closest relative of Covid-19. The SARS epidemic has remained to a significant extent in the shadow, perhaps, because it was perceived in Europe and North America as a regional Southeast Asia problem, a pathology that might upset ‘them,’ but not ‘us.’ It is probably not by chance that ‘SARS territories,’ where memories of an earlier coronavirus outbreak are alive and well, were especially successful in controlling the spread of Covid-19 in the first months of 2020. The writer Fang Fang reported frightening  rumors of “new SARS” that circulated in Wunan in early January 2020 (Fang, 2020). In other parts of the industrialized world, the persistent perception of South Asian people as ‘others’ who harbor different diseases and react differently to them may have favored a rapid forgetting of the SARS epidemic and precluded integration of the experience of this epidemic into the collective imaginary. This oblivion may have in turn hindered the capability of rapidly mounting an effective reaction to Covid-19.

The Covid-19 pandemic is frequently presented as a consequence of the excesses of globalization. But the problem actually may be the simultaneous presence of too much and too little globalization. We live in a world in which, to paraphrase Yanis Varoufakis, money and all that serves to make it circulate freely, even as identities and cultures continue to be separated by high walls (Varoufakis and McWilliams, 2020). In such a world, memories and experiences of groups perceived as different are easily transformed into unknown knowns, hidden in plain sight. (Geissler, 2013. Kelly and Geissler, 2013).


I am indebted to my colleagues from CERMES -3, especially Catherine Bourgain, Soraya Boudia, Luc Berlivet, Maurice Cassier, Jean Paul Gaudilliere and Emilia Sanabria, for fruitful exchanges about the Covid-19 epidemic, and to Vincanne Adams, Claire Baudevin, Carlo Caduff, Silvia Camporesi and Alex Nading for their critical reading of this text.

Ilana Löwy is a senior researcher  at INSERM, Paris. Trained as a biologist, she then retrained as a historian of science and medicine. Her main research interests are material practices of biomedicine, medicine and gender, and intersections between the laboratory, the clinics,  public health, and global health. Her ongoing study of Zika outbreak in Brazil was recently challenged by the advent of Covid19,  above all by stimulating new ways of looking at an epidemics.


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