We need a Covid-19 “re-think”
Most of us are still reeling from the impact of Covid-19 on our lives. Even as we embrace our new, “distanced” lives we must be thinking about the future. When we emerge from our shelters, the relief will be temporary. The development of population immunity, be it through disease transmission and/or vaccines, will allow us to enter the end game of this pandemic, but for that we need to wait. In the meantime, the virus will still be with us and the second act of this battle will begin. So how will we manage going forward? It is murky, but the only clear thing is that we won’t be going back to the way things were for some time.
We can start by learning some lessons from our recent past. The first, and most obvious, insight is that we were under-prepared. We should have known better, after all we have had other outbreaks such as SARS, MERS, and Ebola to warn us that these types of events are full of deadly potential and not as rare as we would like to think. Yet, we have remained resistant to properly investing in something that “might happen” because we prefer to use our resources for something that we need or want more immediately. We are now in the heat of a deadly battle, caught with our pants down, and having to come back from behind. We have seen some responses be more effective than others, but largely, we are not winning this battle (yet). It is time to unearth what lies beneath some of our common mistakes.
Hubris
We have underestimated our enemy, made optimistic assumptions, and have been over-confident in our knowledge and pronouncements. An outbreak is not just another inconvenient matter that can be minimized or dismissed. The truth will eventually out. In this pandemic we have seen not just willful deceit, but a great deal of wishful thinking based on insufficient evidence. When little is known, is it not ultimately wiser to avoid premature assertions (lack of human-to-human transmission, limited transmission from asymptomatic individuals, etc.), acknowledge what is not known, and support actions that minimize risk?
In many countries, the population able to be tested was severely restricted. Would it not have been safer to recognize the virus would find any way it could into the larger population, and that the ability to identify community transmission early would be crucial? Yes, testing capacity was and continues to be limited in many countries, and prioritization in these circumstances is essential. However, had we started with recommendations indicating longer-term objectives for testing, and prioritization of supply that also took into account the need to detect community transmission, we would have likely detected cases earlier and had more supply now.
We have seen a shift by previously resistant public health authorities regarding the issue of cloth masks for the general public. Why did these authorities confidently assure us that masks were of no value to the general public? Was it a case of “not invented here” and cultural resistance? We can ill afford such intellectual snobbery. Was it because masks may not protect the wearer in the way he or she thinks (instead, protecting others from the wearer)? Was it because of supply constraints on medical face masks? Was it because authorities were afraid we would stop practicing other validated behaviors such as hand washing? If so, the messaging was disingenuous. Was it due to the ambiguity in the evidence supporting the use of masks? The choice to take no action is not without harm. We cannot get out of this situation by staying in default mode. Not taking action should require as much justification as does taking action. We must weigh all our options on equal footing, balancing what we know of their potential harm and benefits.
This situation is complex, we won’t have all the data we would like, and recommendations will need to evolve. But authorities need to stop treating trust as a one-way street with no exit. If the public is to have confidence, authorities must reject intellectual complacency and trust the public to be capable of digesting more than overly simplistic dictums. Honesty goes beyond not trying to fool others; it requires that we do our level best to not fool ourselves.
Seesaw mentality
We done a full 180 in a matter of weeks. First, we acted as if the risk from the disease were minor and continued with our normal lives, then we rapidly veered to lockdowns of desperation. Given the long-term nature of this battle, we will need less drastic, more balanced, and sustainable solutions.
A good deal of the difficulty lies in the nature of exponential growth curves. Humans have a known preference to think in terms constant growth (the kind we see with our hair or depicted as a straight line on a graph). We can struggle to really understand exponential growth. We know it is fast, but it is not fast in the way a steeper line grows upward more quickly than a less steep line. It is entirely different because its growth rate at any point in time is proportional to the size of whatever is growing. In short, the more infections, the faster the rate of infections grows. It starts slowly because few infections generate lower growth, but then curves strongly upwards. It can be described in a similar manner as going bankrupt, “slowly at first, then all at once.” Exponential growth is insidious, because the slow start allows us to revert to our preferred constant growth approach of thinking and become complacent. But the curve occurs rapidly, catching us off guard. Then the growth upwards becomes terrifying because it is self-feeding and reaches dizzying scales. The political difficulties in taking early bold action are directly related to its insidious nature. The unrelenting cases and deaths we see are the consequence of its terrifying, self-feeding nature.
When we come out of this current surge, we will effectively return to the insidious part of the curve. We must live with the constant threat of another explosion of cases. However, we must also re-start economies that have been shuttered because we rely on these to sustain life as well. Economic systems must adapt to this new reality and will need to be focused on cushioning those impacted during periods of contraction to ensure individuals and businesses can rebound as quickly as possible.
In terms of public health, the primary objective is to limit transmission. Control can be best achieved if we aim for an infected person to infect not more than one other individual, but this may prove overly restrictive with regards to the economy. Nonetheless, keeping transmission as low as possible will enable us to extend the period of time we are within the lower growth part of the curve. To do this we should follow the approach of those Asian countries which have best managed to tame the growth of cases. Namely, we need continued social distancing measures, use protective measures such as wearing of masks, ensure wide-availability testing and rapid turn-around results, use rigorous contact tracing, and ensure appropriate isolation of cases and close contacts. Despite these efforts, we may still need to periodically to take more restrictive measures to avoid turning the curve into explosive growth, but should aim to keep these periods to absolute minimum. Our best tools to guide these decisions are models, and while we must recognize their limitations, we should expand their use and the contexts which they consider.
We are also innovating to expand our armaments including apps for tracing, diagnostics, drugs, and our holy grail, vaccines. But we may not be sufficiently prioritizing some efforts. Prophylactic drugs that can help reduce the risk of infection if used before or directly following exposure, are imperfect solutions. They are not vaccines and they are not cures. Their protective mechanism is different than those of vaccines and the protection they provide is short-lived, so they require frequent administration. Although a drug used for treatment can also be a viable prophylactic, one cannot assume that a therapeutic will make a suitable prophylactic or vice versa. The route of administration, dosing, safety profile, and efficacy in inhibiting infection matter in determining a suitable prophylactic. Nonetheless, it may be possible to rapidly identify one or more prophylactic drugs through the same approach that is being used with therapeutics, namely clinical trials of repurposed drugs. Although some efforts are underway, we can benefit from a broader, more co-ordinated approach. Even a modestly effective prophylactic has the possibility to be a “game-changer” in our efforts to balance low transmission against economic needs.
We cannot use linear thinking to solve this exponential problem. We must be proactive and sufficiently bold in our measures to limit disease transmission, but we must also ensure that our economies do not flat line in the process. Many countries have fallen well short of achieving this balance, but others have demonstrated that a better balance is possible. Achieving this balance should be our primary objective for the months to come, and as such, we must prioritize access to and development of those interventions that will allow us to better achieve it.
Individualism
Estimation of rates of rates of hospitalization and death have captured our attention. As important as these are, they have also been distracting. This information has been used as a direct means to evaluate risk. Unsurprisingly, many individuals came to the conclusion that Covid-19 was not likely to pose a substantial existential risk to them or to most people. Therefore, they determined that worries around the disease were over-blown. This approach is not without a certain logic, but it suffers from two fatal flaws.
First, this pandemic brings risks to individuals as well as to collective systems. They are linked, but need to be evaluated differently. Systemic risk is not the same as the risk most individuals face. It is evaluated by understanding the nature and scale of potentially disruptive forces and the ability of systems to absorb these disruptions while maintaining function. The threat to our health systems is not determined by those who will weather the infection without need of hospitalization, but by those who will not.
The second flaw is not accounting for the two-way link between systemic risk and individual risk. Collective systems exist to serve our needs. Health and economic systems that are not able to respond to the hugely disruptive forces we now face will be a source of serious risk to the individuals they should serve.
We underestimated Covid-19 because we sought to understand its impact through a lens of individual risk without sufficient consideration of systemic risk. Somewhat ironically, if Covid-19 had been deadlier, posing greater individual risk, our red flags would have been raised much earlier and we might well have had more success in containing it, thereby, ultimately ending up with fewer deaths.
An individualistic approach is also undermining our current response to the allocation of key goods and services. The resources needed to fight this battle, such as protective equipment and ventilators, as well as health care workers, are extremely limited. Substantial efforts now exist to expand the production of goods, but this expansion will never be exponential. Hence we must accept that resources will be limited for some time to come.
Our first response to dealing with this situation has been brutally competitive. It is a dog-eat-dog world, where wealthier and more aggressive buyers win. Under normal circumstances competition can be an effective tool, but in this situation, competition serves to increase the overall cost while yielding worse outcomes because goods cannot go where they are most needed. This competitive reaction is brutal and inefficient, but not without justification: Allocation of scarce resources based on need requires levels of trust and mechanisms of co-operation and co-ordination that are much greater than what we have. When faced with this reality, countries and individuals will do what they must to ensure their own welfare leading to a downward spiral of chaos.
Collective action and solidarity can help us blunt the damage of Covid-19. Societal lockdowns are not enough. We need co-ordinated supply chain mechanisms that prioritize allocation of supply based on need. We need solidarity across countries. Cases flaring out of control in any part of the world, constitute a risk to everyone because there is a limit to how well and how long we can ring-fence ourselves through closed borders. The sooner neighbors and trading partners are able to rebound, the better our own economies (which are dependent on trade) can rebound. We are connected. Nonetheless, to go against the current competitive paradigm at the height of the crisis requires foresight and courage that seems lacking in many of our leaders. It should be no surprise if the value of collective mechanisms and multilateral bodies will be questioned after this current period.
This pandemic is lethal, but most people will survive. We underestimate it when we only look at risk in these terms. It affects all of us- infected or not, asymptomatic or sick- everywhere because it is an assault on collective systems. Those societies that are best able to embrace systemic approaches to assessing risk and collective means to managing the crisis will be better placed to face this battle and rebound afterwards.
