#19: Unreasonable measures
Extraordinary situations call for them.
I’m an author, organizational sociologist, strategy professor, unsuccessful furniture maker, and Xoogler—this is yet another of my attempts to make sense of the state of not-knowing.
tl;dr:
You should be very concerned about coronavirus based on evidence from the last week of developments. You should take action on your concern. This is not the same as panicking about coronavirus. See below for details and justification.
Governments and leaders of organizations should all take disproportionately extreme, apparently unreasonable measures to limit the transmission of coronavirus. See below for details and justification.
When I sent out issue #18 last Wednesday, Italy had 2036 confirmed cases of coronavirus infection, and had reported 347 new cases (as of March 4, 2020). As of yesterday’s WHO situation report (March 10), Italy has 9172 confirmed cases, of which 1797 were new. (All the case numbers in this issue come from the WHO’s daily official situation reports.)
There is no longer any reason to believe that coronavirus response should be “measured” and “sensible” in the conventional way. Responding conventionally to the virus by doing traditional cost-benefit analyses and using the risk mindset implied by those analyses is now absurd given how the situation has developed in the last week.
Conventionally reasonable measures are now available only to countries which responded incredibly swiftly to the prospect of an outbreak and were thus able to contain it early. For other countries where the virus has been spreading, poorly contained, for several weeks, reasonable measures are no longer sufficient. The reality—there is mounting evidence—is that actions taken to slow coronavirus transmission only have clearly visible effects on new diagnosed cases numbers after 10-15 days.
This means that any effective actions taken against coronavirus in the few days before the epidemic curve shoots upward in any country will always look unreasonable and disproportionate.
By the time those actions look reasonable and appropriate, they will be too late.
Lombardy is one of the richest parts of Italy, with one of the best healthcare systems in the country. It is at the heart of the coronavirus epidemic in Italy.
As of today, Lombardy’s healthcare infrastructure appears to be well past breaking point because of coronavirus.
This system is now so far over capacity that the newly released clinical guidelines from SIAARTI (the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care) recommend triage of coronavirus patients requiring intensive care resources.
“Triage” is another way to say that there are now official recommendations about how to choose which coronavirus patients get the limited medical resources that often mean the difference between life and death.
Triage also happens during wars and disaster response.
You can read the SIAARTI recommendations here—in Italian, but you can translate the PDF passably using Google Translate.
(Two weeks ago, on February 26, Italy had fewer cases of coronavirus infection in total than the UK has as of today.)
So: Please be very concerned if you live in countries where the daily number of new diagnosed cases is rising rapidly or beginning to do so.
This list currently includes: Italy, Iran, Spain, France, Germany, the US, Switzerland, the Netherlands, the UK, Sweden, Norway, and Denmark. Outside China, there are coronavirus infections in 109 countries.
The best way to be concerned is to take precautionary measures that inconvenience you slightly (or even a lot) to be responsible to both yourself and others by slowing the spread of coronavirus infection. (Being concerned is not the same as panicking.)
If you’re like most people, you are unlikely to suffer serious ill-effects from being infected by coronavirus. If you are infected, you are also likely to show no symptoms for a few days—during some of which you will be infectious. If you accidentally infect someone who is elderly and/or has pre-existing health conditions, you will quite likely be contributing to their premature (and painful) death. Is this what you want?
The past weeks in China, South Korea, Italy, and other countries suggest that a sizeable fraction of people infected by coronavirus (around 10%) require intensive care. This means that for every 1000 people infected, 100 people are likely to require intensive care. Most healthcare systems have some buffer in their intensive care services, but not a lot. In the UK, the NHS reports about 4100 intensive care beds. Usually, about 20% of these beds are free when coronavirus is not a problem. This means that about 820 intensive care beds are free and available at any time to receive coronavirus patients—across the UK.
You can do the math yourself. A sharp uptick in coronavirus infections will quickly overwhelm this spare capacity in the UK.
(Over 8000 new cases were recorded in Italy in the 2 weeks between February 26 and March 10.)
As more infected patients are admitted to a healthcare system, medical staff become more likely to themselves become infected—this further reduces the chances that coronavirus patients who need critical care actually get it. It also reduces the chances that patients of any other sort who need intensive care get it in a timely way.
If you don’t take precautionary measures to slow the spread of coronavirus infection, you will quite likely be directly contributing to overloading the healthcare system to the point where people die who would otherwise survive. Is this what you want?
This is a realist, completely non-alarmist, view grounded in recent evidence from both Italy and China.
So, let’s assume you’re convinced: you don’t want to accidentally infect people and speed the spread of coronavirus.
The most important thing to do is avoid getting infected yourself.
Conveniently, what you do to avoid getting infected is more or less the same as what you do to avoid accidentally infecting anyone else.
You can reduce the chances you’ll get infected by washing your hands more often, making a point of not touching surfaces with your hands, and never touching your face. (Except after you’ve just washed your hands—then you can presumably touch your face all you want. But maybe you should resist.) Replace high-fives and handshakes with more amusing, non-contact modes of saying hello.
You can get infected and/or accidentally infect people whenever you are close to them. Some common situations when are you close to others include: taking the bus, traveling on a plane, going to a large sports event, going to a restaurant, and attending a conference.
There appears to be not very much definitive knowledge about how coronavirus spreads or doesn’t spread. No matter what the activity, the more people are in the same enclosed space, the longer they are together, and the closer they are to each other—the more likely it is that an infected person showing no symptoms will infect someone else accidentally. And the more diagnosed cases there are in your country, the more likely it is that there will be an asymptomatic infected person will be in that space.
This is why extraordinary, even draconian, social distancing measures should be put in place before the case loads reach the numbers that would make such measures seem “appropriate.”
Simply by reducing the frequency, duration, and proximity of social interactions, the likelihood of getting infected or accidentally infecting someone else goes down. (More here on the extraordinary social distancing measures in China, which have been remarkably effective.)
Until governments mandate social distancing by banning travel and public gatherings, the choice is left to the individual—to you.
Some questions you may want to ask yourself:
Is your holiday or business travel to another country worth the (unknown) probability of accidentally causing someone else’s premature death? This probability is higher (though still unknown) if you choose to visit a country where there are both many diagnosed cases and many new diagnosed cases—both indicate that there are many more undiagnosed cases of coronavirus infection.
Is going to the gig/game/meeting/conference worth the (unknown) probability of accidentally contributing to collapsing your country’s healthcare infrastructure? This probability is higher (though still unknown) the larger, more crowded, and more prolonged the event. (Here’s an example of how one such meeting seriously amplified the spread of coronavirus in the US.)
Is going in to work or to attend classes worth the (unknown) probability of accidentally getting infected and then, while you’re asymptomatic, accidentally infecting other people? This probability is higher (though still unknown) the bigger and more crowded the office/school is, and the more prolonged your time is there.
Now to being purely selfish. Act pragmatically in your own self-interest, but with moderation. Make your life slightly more comfortable as you distance yourself socially. What this means is: Buy and store 2-3 weeks worth of storeable foods and other supplies. You may need a few toilet rolls too, but probably not forty or sixty of them.
At the governmental level: Being precautionary means taking disproportionately extreme measures in response to coronavirus as soon as cases are detected in-country. Immediately.
The more cases are reported in your country, the more immediate and ludicrously disproportionate those extreme measures need to be—but in 10-15 days, those measures will seem completely sensible.
How do we know this?
The first known patient was diagnosed with this coronavirus infection in China on December 1, 2019. In the three months since then, there have been different governmental responses to coronavirus at the national level.
That limited set of responses strongly suggests that:
Immediate and massive governmental commitment of resources to containment (including testing, contact tracing, public education, case monitoring) can dramatically slow the transmission of the virus after the first cases are detected within a country. Taiwan is the example.
Immediate and massive governmental commitment of resources to both containment (massive testing, contact tracing, case monitoring) and mitigation (including draconian-seeming, politically unpopular social distancing measures such as travel limitations and quarantine) can dramatically slow the spread of coronavirus after case numbers begin to spike upwards. The effects of these apparently disproportionately extreme measures take several weeks to become visible. At that point, the scale of the healthcare disaster even given those extreme measures is so enormous that the extreme measures are validated. China and South Korea are the examples.
Case numbers begin to spike upward unless disproportionate containment measures were put in place very early. Nearly every country with coronavirus reports other than Taiwan and Singapore are the examples.
Even relatively well-prepared and well-resourced healthcare systems struggle or collapse under peak load when case numbers begin to spike upwards. Italy, China, South Korea are the examples.
In the extremely unlikely event that you are a reader with influence in your government: Avoiding taking politically unpopular disproportionate measures immediately will almost certainly cause both a massive number of unnecessary deaths and massive economic disruption down the line. Is this what you want?
(If you are in fact this influential reader, please get in touch if I can help make this make sense to the people you need to convince—scroll all the way down for contact information.)
Governments in the US and UK have failed to take any extreme measures so far.
So it falls on individuals to do so, especially in countries where new case rates are beginning to spike upward.
Leaders of organizations and/or people with influence in government have an especially important role to play.
If you are one of these powerful, important people, you may want to ask yourself:
Is it better to take an action that seems unreasonably extreme but will likely be effective early OR to wait until much more extreme actions seem reasonable but are unlikely to work?
Is it better to pay a high price now or pay a potentially much greater, possibly crippling price later?
If your answer is: “I’m willing to be that leader who really leads, who does the unpopular but right thing now! Bring on the unreasonable, disproportionately extreme actions that actually make loads of sense given all the evidence we now have,” then here are two for you to consider.
Immediately:
For two weeks, renewable weekly, move your team/division/organization to working remotely by default (schools can do this too)—grant exceptions on a case-by-case basis.
For two weeks, renewable weekly, cancel all nonessential travel for employees by default—grant exceptions on a case-by-case basis.
(Really, are these actually so disproportionate or unreasonably extreme? If you are one of these leaders, please get in touch if I can help make this make sense to the people you need to convince—scroll all the way down for contact information.)
You’ve Got What It Takes. (I hope.)
If you found this useful or thought-provoking, you should definitely share it indiscriminately with masses of people. You can find previous issues of The Uncertainty Mindset here. I’m on the web at www.vaughntan.org, on Twitter @vaughn_tan, Instagram @vaughn.tan, or by email at <uncertaintymindset@vaughntan.org>.