How We Failed COVID-19

by LukeOnline9 min read2nd Dec 20207 comments

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Since the start of the year, the West has been in the grip of an unprecedented public health crisis. Hundreds of thousands have died, daily life has changed severely and the economy has been dramatically disrupted. It's plausible to call this the West's biggest crisis since World War II. 

COVID-19 originated in China. Despite Asia being the epicenter of the outbreak, the consequences of the virus have been a lot less disastrous there. Taiwan, Vietnam and South Korea respectively suffered 7, 35 and 526 deaths, at the moment of writing. 

In contrast, the Netherlands, Germany and the United States suffered 9518, 17177 and 270642 deaths. Why do Western countries have so much more casualties? It's tempting to say we chose 'the economy' over public health, but that couldn't be less true. Letting the virus spread through entire countries for a long time has been highly disruptive to our habits and thus to our businesses. Compared to for example South Korea, we've had way more casualties, harsher measures for a much longer time, and more economic decline. We're doing worse in every metric. What mistakes are we making?

The Public Doesn't Know How The Virus Spreads

Source: https://english.elpais.com/society/2020-10-28/a-room-a-bar-and-a-class-how-the-coronavirus-is-spread-through-the-air.html

At the start of the crisis, we focused on two main modes of transmitting the virus: via 'big droplets', emitted by for example coughing, and via surfaces. To prevent being infected by big droplets, you've got to keep distance from other people: somewhere between 1 and 2 meters, with different countries recommending different distances. To prevent infection via surfaces, you've got to wash your hands and disinfect commonly touched objects. 

In many Western countries, these are still the main recommended strategies to avoid being infected by COVID. Yet in highly successful countries like Japan, different recommendations have been made from the start. It seems possible to transmit COVID via aerosols, small particles that can float in the air for a long time, and that can fill a room way beyond the recommended safe distance of 1 or 2 meters. Proper ventilation and things like maintaining the right humidity and temperature can help prevent this, but it's highly plausible to be infected while maintaining a safe distance, disinfecting surfaces and wearing face masks. 

I live in the Netherlands, and we've invested a lot in preventing transmission via surfaces. Nearly every shop has a bottle of disinfectant at the entrance. Our Prime Minister recommends us to wash our hands until they're broken. Supermarkets have machines to automatically wash shopping carts, or employees at the entrance who offer to disinfect your shopping cart manually. Too bad transmission via surfaces seems to be highly implausible.

A Total Failure To Calculate Cost/Benefit Ratios 

Let's start at 0 COVID. The virus must be 'imported' from somewhere else. It seems most infected people don't infect anybody at all, meaning you need multiple infections to ignite a wider outbreak. Combined with the fact that testing for COVID has been possible from the start, and the fact that we've even got rapid tests now, this makes it relatively easy to keep COVID out of your community, if you can make sure that those who enter the community are tested. This community can be relatively small (see Formula 1) or large (see New Zealand and South Korea)

Of course, it's possible you fail to protect your borders: an infected person ignites an outbreak inside of the "bubble". It's relatively easy to rectify this situation. Every outbreak starts relatively small, affecting only a small group of people in a handful of places. The full resources of the nation can be utilized to fight this outbreak. A nation's full testing capability can be focused on a small area, and an army of contact tracers can figure out exactly how the virus has spread. A large majority of the nation can continue to live on as they always did - going to restaurants and community gatherings, not wearing facemasks, meeting up with friends and family. 

When you fail to do this, you leave the "green zone" in the graph and enter the white gap in the middle. The outbreak keeps growing exponentionally. Moment by moment, it becomes harder to contain the outbreak. Contact tracing becomes impossible. But while the engine of the virus is "revving up", the negative consequences are relatively benign. Most infected patients feel quite ill, but they'll survive without needing to go to the hospital. The death toll starts rising, but it's relatively low compared to other causes. 

As the death toll keeps growing exponentionally, it reaches astronomical proportions in a couple of weeks or months. Suddenly, the situation looks like Bergamo in Italy, with hospitals totally overwhelmed and morgues unable to cope with the amount of coronavirus deaths. We've reached the red area of the graph. 

This is the trauma that Western policymakers are trying to avoid. Hospitals must not get overwhelmed. Harsh measures will be used to get out of the red zone, back into the "white zone". But these harsh measures hurt the economy severely, so they will be scaled back as soon as possible. These actions are as understandable as the actions of a panicked animal, but they lack foresight and a deeper understanding of the crisis. 

The optimal policy seems obvious to me: get in the green zone ASAP and do what you can to stay there. The  "R number", the average number of people that will be infected by a COVID patient, has to get below one eventually. No Western nation wants to accept a situation where hospitals are completely overwhelmed for many months on end. 

Keeping the R number <1 is relatively easy in the green zone, when borders with high-COVID areas can be closed, and loads of testing capacity and contract tracing are available for every infection. Above the green zone, you'll need to severely affect the daily lives of your citizens: enforce face masks and social distancing, limit visits at home, close restaurants, etcetera. This requires a lot of cooperation from a large part of the populace - something that is a limited resource, which will run out over time. In a crisis, people will adjust their habits for a short amount of time, but this isn't sustainable over a long period. 

The Information Problem

Sacrifices unprecedented since WWII have been asked from citizens. Many billions have been invested in vaccine development, in testing and in hospital care. Many more billions have been lost in the economy. In terms of money and effort, we've done our best. But these efforts have been misdirected, because the public, the media and the government hold the wrong ideas about COVID. A list of very common misconceptions: 

  • Transmission via surfaces is a big problem
  • Transmission via aerosols is not or barely relevant
  • It's fine to hover just below the point where hospitals get overwhelmed - it's not important to bring down the number of active cases as low as possible
  • A vaccine is the only possible long term solution. We can't reduce the amount of infections to 0 any other way, even with potential technical developments like quicker, cheaper and less invasive tests

I'm surprised and shocked by this. I'm a rather pessimistic person, and I wasn't surprised by the incompetent way in which government officials initially tried to tackle this problem. But the stakes are extremely high: hundreds of thousands have died in the West, many billions of economic activity have been lost, and the daily well-being of all citizens has been negatively affected. I had expected best practices and the most up-to-date information to spread pretty rapidly. Back in February, many things were still unclear about the virus. But in April/May, most of the information in this post was already pretty obvious

While many Asian countries were able to contain the virus during their first try, in the first wave, most Western countries failed. Summer bought us some time to prepare for the second wave: many European countries managed to bring the amount of active cases to a very low number. This probably had more to do with the climate, with activities being moved outside, than with the official measures. 

But even with all the information necessary to defeat the virus available, with best practices visible all around us, with many months to prepare, we still failed again. Many will die. The economy will be hamstrung. Our lives are on hold. Many countries apply the same strategies and recommendations that already failed in the first wave. 

It's pretty obvious which mistakes we've made. But why? Why didn't we learn? Why didn't we apply the new information? Why didn't we choose better strategies? 

I find it hard to answer this question with full certainty. The explanation that comes closest in my opinion is this 2019 video about Chernobyl. Some quotes:

What you might not know is that the incident also propelled into in fame the work of German sociologist Ulrich Beck, who, earlier in the same year, finished the first manuscript for a grand social theory called 'Risk Society', that would become a bestseller in the months following Chernobyl.

The theory poses that we have entered a new stage of modernity that is increasingly occupied with debating, preventing and managing risks that we ourselves have produced; that are the direct result of our technological progress.

These risks are unlike any we have faced before, both in scale and in complexity. And because they are inherently connected to many of the essential aspects of modernity, they have infected our society with a fundamental feeling of vulnerability.

(...)

Moments after the incident, we immediately see one of the defining characteristics of modern risks; which is that the danger is pretty much impossible to perceive using our own senses. We are therefore dependent on technology, in this case; dosimeters, to measure the amount of danger we’re in.

This reliance on external risk assessors, of course, puts us in a much more vulnerable position as the series repeatedly shows us. In his book World Risk Society, Beck explains how this expropriation of the senses also means the loss of common sense, and writes that; "Human life is thereby jeopardized to its very core and individuals are robbed of their power of judgement."

It seems that COVID-19 is just too complex for most humans in 2020. Finding accurate information about the virus is hard, with official instutions not always being reliable. Analyzing the way the virus spreads through our society, and figuring out effective measures to combat this, is very difficult. We didn't fail completely, we're not in the worst-case scenario. But most Western countries failed to implement a strategy that would've saved both many lives and the economy, by making some silly errors, not updating their information, and not thinking through the long-term effects. 

If you believe that the 21st century will look much like the second half of the 20th century, this isn't too worrying. A terrible pandemic happened, a lot of older people died prematurely, but the storm will pass and things will continue much like they did before COVID. 

But I think most of us here believe the 21st century will not look like that. New technologies, AI, nanomachines, bioengineering and many other known and unknown innovations threaten to severely disrupt our world. As COVID has taught us, we are not prepared. Our politicians are unable to handle problems of this scale and our media is unable to properly discuss and disperse information about complex topics. In the West, nobody has been able to intervene successfully. 

We are not sure exactly what the future will bring, and whether new capabilities will make it easier to meet future challenges. But they'll probably be as difficult as COVID, and they'll require a response that's as complex as the right COVID strategy. That means that we're currently not ready and that we need to do better. Let COVID be a wake-up call, let us transform our institutions and our mindset to be more capable and effective, and let us not repeat our mistakes on a bigger scale in the future. 

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I wonder whether things could have been different if e.g. one popular TV station compressed the important information into 1-2 minutes, and showed it repeatedly 5 times a day. (10 minutes a day is a rounding error.)

"COVID-19 is transmitted by air in closed environments. Avoid being inside with strangers; and if you must, keep it short, and always wear a face mask."

(Optionally, ending with something positive, which could be different each time. Such as: "If you miss your friends, call them by phone" or "The best way to meet people is a walk in nature" or "Is there a book you wanted to read, or a movie you wanted to see at home? Now is the right time!")

I fully agree that there is a strong lack of proper communication with the public! If all/most citizens have a decent grasp of the "COVID basics" and best practices, ending the pandemic would be a lot easier. 

Except for general information about the virus itself, there should also be some kind of "weather forecast" about the prevalence of the virus in your local vicinity. AFAIK, South Korea was very strong in this regard, at least at the start of the pandemic. Citizens received local reports of how many cases were confirmed in their area. 

I feel like this post is still missing something important about things and that we still don't really understand what has been and is going on.

If you look at the death rate stats from macrotrends (for the USA here but can look at others from the same link: https://www.macrotrends.net/countries/USA/united-states/death-rate) what jumps out to me is that 2018 was a higher rate of growth then either 2019 or 2020 and the latter two are basically the same.

That pattern seems to play out in most other countries.

Well, if the increase in deaths year-over-year was greater in 2018 without COVID-19 than now with the disease, why is this more a problem? Is it a case that those additional deaths (8.8/1000 in 2020 versus 8.7/1000 in 2019) tipped the medical/hospital capacity over the limit? Is it the case that the way the virus works is putting more of a strain on the medical/hospital infrastructure than the greater increase in deaths that occurred in 2018 did?

In other words,is this focus on deaths attributed to COVID the right lens to use?

Related to that question is the fact the projections (at least for the USA) is that the death rate will continue its upward trend to reach about 10.5/1000 in 2050 and those projections do not reflect any impact from the current pandemic.

Again, if COVID doesn't really seem to be impacting death rate trends are COVID deaths the relevant statistic to focus on?

I think your early analysis is accurate, but connecting this to 'reliable information sources about COVID' is completely off the mark. I don't know how to explain properly why I think this is so completely wrong - or at least, not without delving into a few-month sequence based on the material of https://samzdat.com. The 1-minute version goes something like:

There are many possible steps that all need to go right before appropriate collective action is taken to combat a national or global threat. This is especially true if we have shared responsibility, and even more so if the most promising countermeasures involve social changes (i.e. changes in the daily lives of a significant portion of the population). One of these steps is 'having access to proper information about the virus'. A few others are 'having access to rallying points for collective social action', 'willingness to make these social changes, instead of accepting the loss in life and health, in the first place', and I'm sure there are many others. I am not at all convinced that knowledge about the virus is the bottleneck in this process (in fact, I think it is the easiest step of them all). In my opinion the gap between not having accurate information and having accurate information is much much smaller than the gap between having accurate information and collectively acting on it.

Lastly, I think blaming lack of social action on lack of knowledge is a common mistake (maybe even politically motivated tool), and I thank Lou Keep linked above for their wonderful explanation of this point.

This is a very important topic and question, but I fear that you generalize too much and your assessment of Western politicians' understanding lacks subtlety.  In particular, my opinion is that the obviously good strategies were just not politically feasible. In the beginning of the pandemic, I used to treat arguments of the form "The successful strategy of country A is just not possible in country B" as defeatism and status-quo bias, but I  now believe that the South Korean model is indeed not possible in Western democratic countries. This can be seen by creative and smart initiatives of some Western countries that nevertheless failed.

You mention that the government holds the following misconception: 

It's fine to hover just below the point where hospitals get overwhelmed - it's not important to bring down the number of active cases as low as possible

However, the German government is perfectly aware of the meaning of exponential spread, here is chancellor Angela Merkel explaining what R means and why a value of 1.1 would be too high. 

While hand-washing was an important recommendation in the beginning here as well, our public health messaging has been focused for some time now on droplet and aerosol transmission. School and university classrooms are often required to be ventilated at regular intervals (which for most schools is not doable, but that's a different topic). Hand sanitizer is also much easier to implement than any ventilation measure in Winter.

You also invoke the risk society thesis, but this would apply to Asian countries as well, which were able to contain the virus.    

In addition, I think "the summer success in Western countries was not due to measures but due too weather effects" is far too strong a claim. European countries had a decent contact tracing system and cancelled mass events, while the US did not have the first part and had far worse numbers in summer.

 

Why the South Korean model would not work in the West: 

South Korea did contact tracing very well, with huge invasions of privacy like checking CCTV data, publishing the whereabouts of infected individuals and using credit card transaction history. In the US and the UK contact tracers are happy if contacted individuals pick up their phone at all. It's paradoxical, but it seems to me that Western populations would rather accept a wrecked economy, restriction of movement AND hundred  thousands of deaths than a temporary surveillance program. 

 

Examples of Non-Asian countries with smart but failed initiatives:

As far as I can tell, there has only been one Western country to try to eradicate the virus, namely Israel which implemented very tight border control policies and a mobile phone surveillance initiative very early.  However, my impression is that cooperation of the populace is just not high enough, which is why a second lockdown had to be imposed.   

A to me pretty saddening case is the initiative of the Slovak government to test its entire working age population through cheap antigen tests.  Testing was semi voluntary, with the other option being mandatory quarantine. New infection numbers fell very rapidly, but because the testing was done in  parallel with a partial lockdown it's not exactly easy to determine causality. However, since many other European countries with similar lockdowns have at best a flattened curve it seems very likely that mass testing was a great idea which is why it's copied now in parts of England, Austria and Italy.  Despite the large success and subsequent reopening, another round of mass testing has in Slovakia been postponed indefinitely, mostly because the mandatory quarantine got many voters angry and popularity of the government has been waning rapidly.

 

So in conclusion, many smart policies are much harder to implement in Western countries and may actually reflect the preference of the population, and that our current situation is not because of governments "[...] making some silly errors, not updating their information, and not thinking through the long-term effects. " 

However, there was/is room for fairly cheap wins  through scientific and regulatory adaptation. This post is already too long, but briefly put the failure seems to be in those two areas. Despite strong theoretical justifications, no country (AFAIK) has so far approved at home, cheap antigen testing. 

Democracies seem to select leaders who are good talkers, but the selectivity for actual competence looks to be very weak. This is not a surprise; it has been commented on for millennia. Have a look at how ancient Athens got into the disastrous invasion of Sicily which ultimately led to its defeat by Sparta for example. 

Having done polling and talked to average voters it seems to me a miracle that sometimes half-decent leaders gets up. So an incompetent response is expected.

Some things not often mentioned with Taiwan's response to the coronavirus 2 pandemic.

1. They are not a member of the WHO and thus were not misled by their very bad advice early.

2. They had experienced SARS1 and thus did not believe the CCP's misrepresentations of the situation this time around. 

3. Their government seems to be trusted by the population as to competence and as to having good intentions. By contrast from my times in the US, the populace seem to regard the government as a bunch of lying thieves. This makes it much easier for Taiwan to get cooperation. 

4. Quarantine of arrivals was strictly and competently enforced. 

5. Face masks were made mandatory. While annoying to wear, they do not prevent most business and commercial activities.

6. Checking of people at entrances to work, shops, transport, schools etc. Those with suspicious symptoms or a high temperature are sent home. Many have pointed out, irrelevantly, that this is not an accurate test for coronavirus. But it excludes a high percentage of the infected and, with face masks, helps get the R0 infectivity under 1.

7. Some high risk establishments like "hostess bars" were closed, though most businesses remained open and the economy only fell slightly. 

8, Contact tracing was indeed well done and helpful but modeling suggests it is not enough on its own. You need to get infectivity down and keep from importing cases as much as possible. 

These are all good points! They remind me of the "Swiss Cheese Model" in regards to COVID. No single solution is 100% effective, but combine enough layers and there won't be any 'holes' in the strategy anymore.