To me, the term “surreal” means dream like reality. That is what I felt when sitting at a table in my local Chinese restaurant in Rome. I noticed the waiting staff looking nervously at the sparse (Italian) clientele. After paying the bill I asked the Chinese-Italian owner what was going on.

The answer came as a bit of shock: “my staff [all Chinese] are afraid of getting infected by the customers.”

Driving home I reflected on the meaning of what I had heard. Perhaps the covid-19 epidemic started in China and perhaps it spread from there to other nations. The timing of the spread of the virus (3 months) fits with international travel norms. There are instances of well recorded chains of contacts. However there are also sporadic cases with no obvious contact with infected people. In addition, the frenetic media coverage can distort perceptions and present them as facts.

One need not look any further than the story of the so-called Spanish influenza of 1918-19. Spain was where the majority of cases were reported because military censorship was in place in the rest of Europe, the Far East, and North America. That’s why the pandemic became “Spanish”. There were plenty of cases of unexplained transmission then as well. The events of the tiny Pacific islands of Western Samoa are a very good example. When the New Zealand Navy relief expedition arrived at the end of 1918, they found that out of a population of 36,405, nearly 20% (7,264) had died in a very short time. Samoa had had no outside contact for months. So where had the bugs come from?

A score of similar situations were reported by eye witnesses in The BMJ at the time. There was also a tentative explanation of the incredibly high mortality rate: contextual factors. Samoans were bathed in the sea after the third day of fever, with consequent pneumonia and death. For covid-19, mortality seems to be associated with a lowering of immunity and pre-existing morbidities. According to Major Greenwood, a very careful observer of the 1918 pandemic, isolated cases of previous plagues were noted and recorded simply because of the high mortality rate of the disease. Not so for influenza, which has a lower mortality rate, so cases are reported in clumps giving the illusion of synchronicity even wide apart. Very many other contemporary observations from the great pandemic have been forgotten, such as the relative immunity of munitions workers to influenza, especially those who were manufacturing chemical weapons to be used in the trenches or the preventive effect of sniffing gas from lamps (something only campers could do today) . 

An accurate description of what is going on at present with a careful eye on the reporting patterns through official channels and the media could help elucidate the mechanism of spread. It could also clarify whether some of the observations are real phenomena or fallacies.

I think this may be the most important legacy of the covid-19 outbreak: the realisation that we need an international effort to document the outbreak, its history and evolution. Like John Snow with the widow of Hampstead, we need to investigate the extraordinary to see if it can shed light on the ordinary. This effort needs to continue long after the outbreak is over and could be an ideal project for a global donor that wants to diversify its donations. Diaries, interviews, articles, multimedia records curated and indexed could finally help us understand a bit more about respiratory viruses, their ecology and how they ultimately cease being a menace.

We might then understand whether waiters infect customers or vice versa.

Tom Jefferson is an an epidemiologist and Cochrane researcher, based in Rome, Italy. 

Competing interests: Please see full statement here