TLDRUpFront: We examine the five emerging national strategies to confront COVID-19: People’s War, Pandemic Panopticon, Mobilization & Lock Down aka “People’s War Lite”, Fire Break, and Induced Herd Immunity. We contrast this with the recent national approach in most of Europe, the United States and Canada of “business as usual” and how that early response set the conditions for more dramatic action being required now.
Pandemic Panopticon in South Korea
FullContextInTheBack: Without a unified strategy to confront the COVID-19 global pandemic, different nations have begun diverging into five “template” approaches. This article provides a brief overview of how a “business as usual” approach in Europe and the United States failed to consider the emerging new reality, and then reviews the five different approaches.
The Failure of Business as Usual
In both Europe and the US an early response of “business as usual” prevailed, though it manifested in two different forms.
Downplay & Debacle
In the United States the President and his administration downplayed the risk of the contagion at every chance they could find a microphone. This both undermined their own experts stating otherwise, but also conveyed false assurances to the loyal Trump base who took to heart when on February 28th, the President said ““It’s going to disappear. One day, it’s like a miracle, it will disappear.”(1)
But if Trump was hoping for a Coronavirus Miracle on 34th Street ending, what he got instead was a debacle of Greek tragedy proportions. The initial problems began when the CDC decided against adopting existing testing kits approved by the World Health Organization (WHO) and instead made a policy choice to wrap COVID-19 testing in with other flus. This extra complication led to wasted time in design, production, and an ultimate recall as the kits themselves had a quality flaw in them. (2) This lost crucial weeks of time in early to late February, even prior to the President’s promised disappearing act as a new kit had to be designed, produced and distributed. This shortage required guidance to be issued on determining who would be tested – limiting the ability to know where the virus was and where it might be heading next. And although kits have become more available, and guidance shifted, the conflicting instructions have confused many doctors which are still giving old guidance to those concerned with infection, leading to lost confidence in the public.
The lack of confidence reached peak-Trump during a White House address March 11th where the President attempted to calm the nation, and the stock markets, with a series of new measures. But a travel-ban announced with no warning or preparation led to packed conditions as US citizens and residents abroad tried to return before flights stopped, leading to prime contagion conditions. (3) The stock market took the President “seriously and literally” and proceeded to drop 10% the next day. (4)
By the end of the week it was clear that President Trump hadn’t pulled off his COVID-19 magic trick. But he did make two things disappear: the unity of his base in having confidence in him and about a third of the stock market value. The United States abandoned its business as usual approach and adopted instead a Fire Break approach, see below, approach as the President declared a national emergency.
Bit by the Dog
Europe’s version of business as usual differed from the United States. It didn’t lack for testing equipment or a will to test broadly. What it lacked though was a sense of urgency by politicians and the population. They adopted an approach similar to dad-advice on how to avoid getting bit by a dog: walk tall, don’t show fear, and you’ll be fine. Across Europe this form of stiff-upper-lip prevailed in the early stages of each country’s contagion. In Italy and France citizens dismissed urgent warnings to change behaviors and went about normal routines high in social interactions. In the Netherlands official guidance for weeks encouraged the population to continue working and socializing, despite being symptomatic, if “they felt well enough.” (5) Germany refused to entertain social distancing and isolation until late Friday night, even as Italy’s healthcare system was collapsing.
As a result, Europe, including the United Kingdom, Ireland, Nordic and Mediterranean countries is the hardest hit region in the world. Europe represents just 10% of the global population, but as of MAR 16 WHO Data accounts for 36% of all global infections, ~65K confirmed cases, and 40% of all deaths around the world at ~2,800 deaths.
If this is evidence of failing to flatten the curve in general, Italy is the case-study in specific. With hospitals in northern Italy overwhelmed, doctors had to make war-time triage decisions for lack of ability to treat everyone. (6) As a result the death rate in Italy has been steadily increasing upward to over 8% as of March 17th. A lot of media has whistled past the graveyard on this, citing well known demographic realities that Italy is the eldest country in an increasingly elderly Europe.
But it would be a mistake to think of this as an age-only or Italian-only problem. That the death rate is dynamically increasing, rather than at a flat but higher rate speaks to some form of increasing inability to deliver services, regardless of age, as shown in the chart below.
Dynamic death rates as % of confirmed cases over time.
In neighboring Switzerland, a federal health official warned that the Swiss hospital system could collapse by the end of the month if infections keep on pace. (7) And the discussion among the medical community there is not on whether they’ll have to use extreme is they may have to soon take similar extreme triage methods – but what ethical guidelines should be followed when it happens. (8) Meanwhile evidence mounts in Iran, a country that skews much younger in population than Europe, of a death rate climbing as well, now over 5%.
Needless to say, the European model of walking tall and strong past the dog has been abandoned after a furious mauling. Most mainland countries have shifted to a Mobilization & Lock-Down approach or, in the United Kingdom, to Induced Herd Immunity.
The Five Templates of National Responses
The People’s War
The first national template of response, China’s response, was named “the People’s War” by General Secretary Xi may also be called a “war on the people.” After having initially suppressed information about the virus and warnings the Chinese government faced a run-away epidemic and responded in authoritarian fashion. They implemented strict quarantines on over a dozen cities with a population exceeding 50M. This was considered by some the largest human quarantine in history until Italy exceeded it recently. (9) The People’s War marshalled state civilian, police, and military personnel to enforce draconian quarantine conditions on the population including carving cities into zones that were then physically separated from one another with barriers. But the People’s War also resembled a war in the rapid erection of fixed facilities – one hospital was built from scratch in under 10 days and another dozen were constructed during the course of the outbreak. Having failed to #FlattenTheCurve, China decided to try and out build it.
On paper this appears to have worked. According to WHO Daily Situation Reports China has reached a peak of the s-curve and reduced new cases to a crawl. That’s on paper. The trust in Chinese reporting is low right now, based on their earlier policy of suppression and misinformation. Having looked at the data if China is hiding the numbers they’re doing an adequate job of making the data look real, unlike, say, Iran. Not only have confirmed cases dropped steadily but confirmed deaths have as well. Of course, they could be under-reporting that as well.
The challenge with the People’s War are numerous to implementing in other countries. The most obvious being gross and widespread of violation of civil liberties under what amounted to authoritarian martial law. But right along side that strict quarantines enforced by the state are a means of coercion – which is more resource intensive than self-adopted measures by a population to manage themselves , see Pandemic Panopticon. The allocation of resources to enforcement creates a natural backlash to resist those measures – and as soon as a wall is put up someone’s going to figure out how to go over, under, around or through it with a bribe. This calls into question how “tight” a quarantine can ever be and whether for focusing on those efforts a great deal of spread is missed.
People’s War style quarantines also create considerable resentment in the population, meaning their feasibility over the long run is dubious. Stranded residents had difficulty obtaining food or necessary medication for other conditions. Business of any kind, having no preparation for the severity of the lock-down had no ability to function an unemployment is widespread. Indifferent callous treatment of both patients and relatives of the deceased led to increasing grievances in Hubei province and Wuhan city, the two areas hit hardest. This will be covered in more detail in a future InfoMullet article on potential instability arising from COVID-19. But it’s noteworthy that for a country praised externally for having contained the contagion, little of that praise is coming from inside the areas hardest hit that had to live within the People’s War.
Notwithstanding these concerns, Malaysia recently adopted a People’s War style response, Iran is considering it and it may be the go-to favorite of authoritarian and less-democratic regimes.
Mobilization & Lock Down (aka “People’s War Lite”)
After the business as usual approach failed, most European countries are beginning to adopt a lighter friendly version of the People’s War. This involves strict quarantines, restricted travel and mandatory stay-in-place orders to wide portions of the population. In many countries, including France and Switzerland, national guard units have been mobilized both to help police the lock-down and provide extra resources to responding to the contagion. France is now issuing fines to people on the streets without approval. (10) All of Italy is now on quarantine, exceeding China’s previous ‘largest quarantine ever’ by over 15M people. The European Union has banned travel across its exterior borders and most European countries are beginning to ban travel across interior borders as well.
This is a much lighter version of the People’s War, however. Trips are still allowed to be taken under more lenient conditions than in China. But not necessarily for long.
The most effective current responses are demonstrated in countries that had prior experience dealing with SARS and MERS, two respiratory related outbreaks in the 21st Century confined to Asia. A panopticon is a concept of a prison where one guard can observe and see everything that all prisoners do all the time and has since become synonymous with total-awareness government systems that make privacy outdated. In a pandemic however, the ability to understand, monitor and share information can be effective in containing the spread.
The Pandemic Panopticon approach combines extensive education, prolific testing, and careful surveillance and tracing of all infected cases to build a full awareness of every infected individual. This is the “guard” who “sees” where all the “prisoners” are located in the system. This information is then shared back to the public through mobile applications that provide exacting details on the location of infections. Combined with extensive education to the public of what and how to respond this allows the population to self-organize around the infected. It is a quarantine in reverse. Instead of isolating the patients from the population, the population isolates itself from the infected. This bypasses the need for draconian measures in the People’s War and is less resource intensive as individuals self-manage. This frees resources to target the infected most in need. The effectiveness of the Pandemic Panopticon is visible in South Koreas ability to curb an outbreak at much lower levels that China was, as shown in the chart below.
Comparing China and South Korean responses at effectiveness in containing an outbreak.
It is not without its downside, however. The first being that current privacy laws in most of Europe and the United States would prohibit the gathering and disseminating of such information. The Pandemic Panopticon is a privacy advocates worst nightmare. It also is being used in mostly homogenous, well-educated, populations where retaliatory harassment and attacks on those considered to be “other” isn’t as high a risk. Finally, and of most practical importance, it only works if testing is widespread enough and subsequent surveillance and tracing good enough to find all the cases. There’s a reasonable argument that, even if privacy laws could be lifted by emergency decree, the window of such measures in European and North American countries has passed.
The national response adopted by both Canada and the United States in the last five days can be described as a fire break. It differs from the lock-down approach of European countries in that it relies on voluntary cooperation. The concept is to encourage everyone: individuals, community organizations, businesses to self-isolate where and when possible in the hope that creates a ‘fire break’ from the approaching wildfire. No fire break will ever be perfect, nor is this approach intended to stop the fire cold. But it may slow it down significantly as the United States enters a crucial period in the next 10 days to flatten the curve. If the rate of infections slow in growth, the hope is the existing health care infrastructure can handle it.
What’s surprising is how fast the landscape of these countries have changed as mass-cancellations of events, lift-and-shift of entire workforce and university systems online has begun. It has put both Canada and the US in a slightly better position of Europe which had to enter lock-down conditions.
The problem with the fire break, at least in the United States, is twofold in the short term. First is it’s voluntary. In addition to the travel-ban-induced hot spot of contagions at national airports it was clear that the fire break was not universally adopted. Bars remained opened celebrating an early St. Patrick’s Day and were in many cases packed. Many Churches and community events continued to meet. This is in part a reaction to the “business as usual” that came from the President for so long. Trump’s base, at this point conditioned to believe everything he says, believed that this will pass more than this was urgent. This is dangerous considering the President’s support skews older raising the risk that continued belief in Trump-ical infallibility results in a non-trivial amount of his base dying or suffering serious consequences as a result of COVID-19 exposure.
Induced Herd Immunity
The United Kingdom approach is unique among all the countries – which is to induce a herd immunity among the population. This is done by keeping events, businesses, schools and social gatherings open for younger, healthier populations while encouraging isolation of at-risk populations. It is based on a mental model that the COVID-19 outbreak will mirror the 1918 “Spanish Flu” influenza pandemic that infected 27% of the world population and killed between 17M-50M people. In that outbreak, which consisted of three “waves” of the 1918 Influenza outbreak. The first wave in the spring had some effect but was followed by a second deadlier wave in the fall. Some research speculates that the timing of the second wave had to do with initial isolation and quarantines that gave a false sense of security. As soon as those were lifted in fall, schools reopened, the influenza hit hard. (11)
In the Spanish Flu younger and healthier adults were more susceptible to falling ill and dying due to the cytokine storm effect of that influenza. In COVID-19 however the mortality rates are far higher for elderly and vulnerable populations.
The induced-herd immunity approach leverages this feature of COVID-19 mortality skew to create a population-bulwark against future spread and keep the curve flat on hospital visits during the first wave. The hope is the larger, healthier, and younger population will actually begin to be exposed and build immunity to it. This is why the United Kingdom is not closing schools, events, or encouraging businesses to work remotely. Instead they are focusing on the vulnerable population to isolate them during this first wave while herd immunity is established, since the total lifecycle from infection, symptoms, to recovery appears to be ~1month. If fewer elderly or vulnerable get sick it should reduce load on hospitals.
There’s a tricky timing aspect and several crucial assumptions. Models do not show reaching herd immunity in the first wave prior to the curve of demand for critical healthcare services exceeding supply. UK officials are monitoring the rate and will impost European Lockdown or Free Market Fire Break style measures as it appears the healthcare system is about to succumb. This video demonstrates the concept.
The problem with this kind of timing is that the material spread of the disease exceeds the information spread which forms our perceptions of where it is at. Even confirmed cases by testing only tell us where the contagion has spread 5-12 days prior. Not where it is now. This gap in perception versus system state is significantly longer than the doubling period of the virus at full tilt which is 2-3days. In other words, if the United Kingdom is off by even a week in their timing of instituting isolation and quarantine, the virus contagion may have quadrupled in size, resulting in a collapse of the healthcare system all the same.
That’s not the only risk. The entire approach of induced herd-immunity assumes that surviving first exposure gains immunity. If the virus can re-infect, or mutates as it storms through the population, then second and subsequent waves may not be deterred to the acquired immunity. And it is largely based on the theories of a single paper widely distributed within the UK government. (12)
Induced Herd Immunity is the Texas’ Hold ‘Em equivalent of going ‘all in.’ If the United Kingdom is wrong the approach is like pouring gasoline on your own house while it’s burning. But if they’re right, they may be the only country spared from a far more serious outbreak later in 2020.
Trading Risks: How can an informed reader evaluate policy trade-offs of harm and risk?
A final note on the evaluation of these policies. None of the approaches above are perfect at current nor have any proven to withstand the test of time because we don’t know where COVID-19 stops. All of them contain both harm and risk. In the Pandemic Panopticon a complete loss of privacy, in the Fire Break economic damage, in Lock Down and the People’s War a loss of civil liberties, and in Induced Herd the risk of miscalculation that the whole exercise was wasted. From a policy perspective this is the space I normally live in, which is the trade-off of harm and risk when it comes to weighing potentially catastrophic results. My normal research is in violence and instability, specifically terrorism, insurgencies and other forms of mass-violence.
When evaluating these policies, we have to remember this is an environment of ambiguity – no one has enough data to make an objectively “right” decision, and at the level of national response it’s a given all choices will create harm. What matters most in evaluation is both potential efficacy of the solution, but also whether policy decisions are reversible and their harm able to be mitigated.
Consider the Fire Break approach of the United States. Assume the given we don’t know yet what we should do and evaluate the two policies:
Scenario 1: A voluntary social distancing and event cancellation policy like in the US causes tremendous economic harm. But if the data comes in two weeks from now “we were wrong” the policy is reversible. We lift the restrictions and things go back to normal. The harm inflicted, economic can be mitigated with support programs that are already working through Congress.
Scenario 2: Contrast with the opposite. We keep on as we were waiting for more data to come in. Two weeks from now we find out “we were wrong” and have now replicated the #FlattenTheCurve scenario in Italy on mass-scale. The problem here is the policy is not reversible. We can’t go back in time and change what we did, and the contagion can’t be put back in the bottle for a similar level of harm, it may be for a higher level of economic harm, but the earlier option is no longer available. And loss of life/debilitating sickness is a much harder harm to mitigate after it’s happened than an economic harm.
These are not easy questions. But knowing the responses above, and this kind of evaluation in risk trade-off should make us more informed in advocating for better solutions from all our governments..