This article first appeared in Forum, The Edge Malaysia Weekly on May 25, 2020 - May 31, 2020

Since May 2020, many countries around the world have begun to emerge from an extended period of lockdown and extreme social distancing that was enforced to “flatten the curve” of the Covid-19 pandemic.

No country has yet eradicated the disease. New Zealand, Australia, South Korea and China have come close, but they all still have restrictions. Even after recording zero new daily cases, South Korea has seen a recent cluster emerge, as has China. Others are acutely aware that they have not eradicated the risk. Like Malaysia, these countries have made measured policy decisions to minimise the public health risk, weighed up against the economic, social and mental costs of limited social mobility.

The same principle applies to businesses, organisations and individuals. As we re-emerge into our offices, factories, construction sites and retail outlets, there is a new level of risk that we must manage, not just for ourselves, but for our families, employees, the health system and society at large. But the risks and costs are not evenly distributed.

For example, elderly persons or those with an underlying co-morbidity need to be particularly cautious. Individuals working in high exposure jobs, for example those in a health setting, will naturally take extra precaution, but possibly more so if they live with elderly relatives.

So learning to live with Covid-19 begins with informing ourselves of the latest scientific evidence and public health practices as a basis to define our risk thresholds and acceptable activities. It helps to first contextualise the risk by understanding its origins and acknowledging that “the virus” is not a foreign agent or invisible enemy per se, but rather the product of our collective behaviour over the past two centuries, which have accelerated in the past few decades. Part of our approach to tackling Covid-19 has to extend beyond the public health crisis. It must also seek to resolve underlying systemic issues that have led to the pandemic, and the vulnerabilities that it has shone light upon.

Origins of Covid-19 and risks of modern society

The scientific community holds that SARS-CoV-2, the virus that causes the Covid-19 disease, is zoonotic. It most likely originated in wild animals in central China, with the first transmission to humans occurring in late 2019, either in a Wuhan wet market or within its vicinity. The Horseshoe Bat is suspected as the virus’ most likely host reservoir, with Malayan pangolins (Manis javanica) suggested as a possible intermediate species.

Viruses jumping the species barrier and causing respiratory illness in humans is not new. The 2002 Severe Acute Respiratory Syndrome (SARS) outbreak, which caused over 800 deaths, originated in bats (and then civet cats). Similarly, the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) likely originated in dromedary camels.

While it is rare for a virus to emerge from the wild, it is common for humans and domestic animals to “share” respiratory illnesses. This is evident with swine, which can be infected by both avian and human influenza strains and become reservoirs for mutations and further outbreaks. H1N1, which was responsible for the 2009 influenza pandemic and some 280,000 deaths, evolved as a result of co-infections and strain mutations between poultry, swine and humans. A similar process is believed to have occurred in the 1918 Influenza Pandemic that caused some 50 million deaths.

Respiratory diseases arising from human relationships with animals, domesticated or otherwise, is increasing in frequency. As the human population grows and its demand for meat and other products from domesticated and wild animals increases, so does the risk that we will be exposed to more virulent and novel strains of disease. Likewise, as the footprints of our cities and towns expand, we push deeper into natural lands, disrupting ecosystems and bringing animals into closer contact with human systems.

When a pathogen does find the opportunity to cross over, it will — such is the nature of opportunistic infectious diseases. As we have seen with SARS-CoV-2, it can take advantage of globalisation’s hypermobility and replicate at remarkable speed. This is an important point, which was articulated in a recent Think City policy paper, Reflexivity in the Age of Pandemia: Adaptive Policy Making and the Covid-19 Crisis (Benson and Faiez, 2020), where it is highlighted that pandemic disease is not an external threat, but rather an externality of a highly connected and interdependent modern industrial society.

Transmission routes and risks

In understanding the risks associated with our re-emergence from the Covid-19 lockdown, it is timely to remind ourselves of some key terms and facts related to the disease. The first is that Covid-19 is predominantly a disease of the upper respiratory system, transmitted through exposure to droplets from coughing or sneezing and saliva from infected individuals.

This is then transmitted directly to uninfected individuals in close proximity (within one to two metres) via the mouth, nose and possibly eyes. It can also be transmitted indirectly from high-touch surfaces (door knobs, hand rails and shared electronic devices) onto our hands, then into the respiratory system when we touch our mouth, nose or eyes.

A second important fact to acknowledge is that SARS-CoV-2 is highly contagious. It can be transmitted by symptomatic and asymptomatic individuals. Its R0 value (the rate of reproduction, pronounced R nought) is around 2.5 in a normal social setting. This means that without physical distancing measures, the average number of people who will be infected by SARS-CoV-2 from one patient is at least two and possibly three.

Normal influenza and H1N1 have R0 values of between 1.4 and 1.6. However, this is not a static number as it changes depending on social behaviour, and is therefore one of the most important average national numbers to monitor. A R0 value above 1 means that the virus continues to spread, while a value below 1 means it will die out. The director-general of health has indicated that before the first phase of the Movement Control Order, the R0 value in the country was over 3, but had been reduced to below 1 by mid-April. It is currently estimated to be 0.3.

So, in terms of living with Covid-19, it is important that we modify our behaviour and adjust policy measures to ensure the R0 stays below 1. This will vary for different countries. In some, weather may play a role, as might cultural norms and gestures. For example, the handshake may no longer be encouraged as opposed to a Japanese bow or Indian “Namaste” greeting. Risk then becomes a cultural value — behaviours sacrificed in one culture or context may not be necessary in another. The same line of thinking applies to the way we organise our homes, offices and businesses, and again we must turn to evidence to make the right decisions.

Disease progression

Data from China, Italy, the UK and the US in March and April this year suggests that up to 15% of those with Covid-19 require hospitalisation. The elderly and patients with co-morbidities, especially obesity, diabetes, cardiovascular issues and recent cancer, are particularly susceptible to more severe forms of the disease. Men also seem to be more susceptible.

Notably, across all countries, the case fatality rate (CFR) has generally fallen in the last month due to a combination of wider testing, improved treatments and identification of asymptomatic and mildly symptomatic individuals. It is now estimated that the CFR is less than 1% in the general population, but as high as 10% in people over the age of 70. However, it should also be acknowledged that even in New York, many deaths due to Covid-19 have not been accounted for, so the CFR may well change in the future.

The Australian Broadcasting Corporation reported this week that New York doctors continue to be surprised by disease outcomes. Mount Sinai Hospital’s head of intensive care has described Covid-19 as three separate diseases — the mild flu-like respiratory illness that most will experience; a more severe form that causes multiple organ damage; and a rare form of illness in children with similar symptoms to the Kawasaki disease.

While it is still evident that the majority of Covid-19 cases will be mild, we do not know its long-term health impacts — what is known in the medical field as sequela. Immunity is probable with many recovered patients testing positive to antibodies in recent weeks. But how effective these are or how long immunity lasts is unknown.

Beyond the Covid-19 crisis

The fact remains that there is still a lot we do not know about the SARS-CoV-2 virus or the Covid-19 disease that it causes. The more we know, the less uncertainty and the more calculated the risks we can take. In time, Covid-19 will likely become a manageable disease. We may find a vaccine sooner than expected. There is even a remote possibility that the world collectively keeps its R0 value below 1, and the disease simply burns out. Whichever occurs, life will not return to pre-Covid norms.

The post-Covid world still remains elusive. Global crises have a tendency to compress history and accelerate trends already in motion. The fundamental questions that we need to ask are — if we truly want to emerge from an age of crises created by our relationship with nature, how do we adapt to the environmental changes we have triggered and how do we best reverse the damage done?

So much depends on our scientific, economic, political, community and environmental efforts in the weeks and months ahead. The way we use public spaces, the roles of urban planning, cities, institutions and the economic model we pursue all need to be reconsidered. This may mean re-examining our food supply chains, reining in urban expansion, reconfiguring transport systems and finding more holistic ways of seeing and understanding the complex and interconnected world around us.

In the past few weeks, many international voices, including the German Chancellor, Canadian prime minister and French president, have spoken about a new world. The UN secretary-general has called the Covid-19 crisis an opportunity to “restart” and create a healthier and more resilient society. Many have called for recovery plans driven by a green agenda, not a return to the extremes of the neoliberal systems of old.

There are already signs that the reality of Covid-19 lockdowns is changing societies and economies. Microsoft’s CEO stated last month that the company has seen two years of digital transformation in two months. National governments are reviewing the vulnerability of their supply chains, especially for food and medical supplies. Food miles may decrease and factory-like farming designed to supply global fast food outlets may be less viable in a post-Covid 19 world.

Just-in-time delivery systems may be replaced with more resilient structures and redundancy. It may be that the basic incomes guaranteed by some governments in the last few months, coupled with industry disruption, will force new perspectives on ways to address inequality.

These scenarios are more possible now than in the pre-Covid 19 era, largely as the psychology of the average global citizen has changed to varying degrees. Images of dramatically lower pollution levels, wild animals roaming streets and overwhelmed health systems in some advanced countries, will throw in doubt the continued pursuit of growth for the sake of growth. Many have also had time, or been forced to take time, to reflect and question their values.

The world is on the cusp of a major socio-political shift. It is not guaranteed to be progressive, but there are promising signs that it might be. The Covid-19 crisis has shown to a certain extent that it is possible for government, business, academics and community to rally around a common purpose. The key is to harness this momentum and use it to address the deeper structural and climate-related challenges we currently face.

Hamdan Abdul Majeed, a former investment banker, is the managing director of Think City. Through various public and private roles, he has been actively involved in shaping urban policy and plans in Malaysia for the last 15 years. Matt Benson is an Australian geographer specialising in complex systems and human settlements.

He is a programme director for Think City and is based in Penang, Malaysia.

Think City is a social purpose organisation dedicated to making cities people-friendly and resilient by being a catalyst for change in the way cities are planned, curated, developed and celebrated.

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