Donald Rumsfeld would have been a reliable health czar during this coronavirus crisis. His “unknown knowns” and “known unknowns” serve us well now. The tautological “we don’t know what we don’t know”  is a good place to start.

Rather than going into how this all unfolded, let’s look at a few points in the darkness.

The study that underpins the Western response

When western leaders, particularly in the UK and US, were presented a draft of a soon-to-be-published report on or around March 10 their blood ran cold. Sobered and afraid, they read with growing horror the numbers that would rip their countries apart. Suddenly US President Donald Trump’s claims about the coronavirus being like the flu, or UK Prime Minister Boris Johnson’s theories about “taking it on the chin” and “herd immunity” evaporated.

It was the “crucial piece of evidence” that spurred Downing Street to act, say researchers who “first realized the scale of the problem in China,” noting their “advice is heavily influential in government.”

The report, titled: ‘Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand’ and published at the Imperial College London by 34 authors, with Neil M. Ferguson, listed first, was  done on behalf of the Imperial College COVID-19 Response Team WHO Collaborating Centre for Infectious Disease Modelling and the MRC Centre for Global Infectious Disease Analysis as well as the Abdul Latif Jameel Institute for Disease and Emergency Analytics, Imperial College, London.

Published publicly on March 16 notes that the real problem with coronavirus is it  will overwhelm western health systems. Researchers have some notes: “Two fundamental strategies are possible: (a) mitigation, which focuses on slowing but not necessarily stopping epidemic spread – reducing peak healthcare demand while protecting those most at risk of severe disease from infection, and (b) suppression, which aims to reverse epidemic growth, reducing case numbers to low levels and maintaining that situation indefinitely.”

Depending on the numbers, “in total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in GB and 2.2 million in the US, not accounting for the potential negative effects of health systems being overwhelmed on mortality.” Later numbers appeared slightly lower: “UK epidemiologists have predicted that without drastic intervention, the coronavirus could overwhelm intensive care units and lead to up to 250,000 deaths in the country and more than 1 million in the United States.”

In the study they also argue “We show that in the UK and US context, suppression will minimally require a combination of social distancing of the entire population, home isolation of cases and household quarantine of their family members. ” But this could go on for a long time. “The major challenge of suppression is that this type of intensive intervention package – or something equivalently effective at reducing transmission – will need to be maintained until a vaccine becomes available (potentially 18 months or more) – given that we predict that transmission will quickly rebound if interventions are relaxed.”

They believe “In the case of COVID-19, it will be at least a 12-18 months before a vaccine is available.” Massive numbers go undiagnosed. “Analyses of data from China as well as data from those returning on repatriation flights suggest that 40-50% of infections were not identified as cases.”

Without controls: “We would expect a peak in mortality (daily deaths) to occur after approximately 3 months (Figure 1A). In such scenarios, given an estimated R0 of 2.4, we predict 81% of the GB and US populations would be infected over the course of the epidemic…For an uncontrolled epidemic, we predict critical care bed capacity would be exceeded as early as the second week in April.”

They concluded that voluntary measures and stopping large gatherings wouldn’t do much, because people spend most of their time at the office or school. “Suppression is likely necessary in countries able to implement the intensive controls required.” It could continue for months. “Measures are assumed to be in place for a 5-month duration…such a combined strategy is the most likely one to ensure that critical care bed requirements would remain within surge capacity.” But they warned: “Introducing such interventions too early risks allowing transmission to return once they are lifted (if insufficient herd immunity has developed).”

Also they noted: “To avoid a rebound in transmission, these policies will need to be maintained until large stocks of vaccine are available to immunise the population – which could be 18 months or more. Adaptive hospital surveillance-based triggers for switching on and off population-wide social distancing and school closure offer greater robustness to uncertainty than fixed duration interventions and can be adapted for regional use.”

There is no plan B

While governments began acting based on aspects of this report on March 11, many of them assumed there would also be results. They hadn’t read the full implications of the tunnel they were entering. On March 9 Italy expanded a regional lockdown to the whole country. Around 1,000 people had died by March 12 in Italy. Some officials understood that this might be longterm. The public was not warned. Foreign Policy noted that a similar lockdown was coming for the US. They quoted one person as saying “see you in September.”

The desire to see some results from the lockdown left people sobered when it didn’t happen. “Italian doctors don’t know if the coronavirus lockdown is working. But there’s no plan B,” reported CNN on March 19. Indeed there were 4,200 more cases in Italy on march 18 and 475 more deaths. “Italy’s mortality rate has been far higher than the key study which had estimated mortality at around 9% for those over 80 but .08% for those in their thirties. That study had shown that for the elderly some 27% require hospital care and of those around 70% require intensive care.”

The Italian response was described by CNN: “The stores that remain open are shuttering earlier and police are patrolling in ever-greater numbers, chasing families out for walks back into their homes and ensuring no one is outside without a valid reason.” When the article was written around 2,500 were dead in Italy, by the time the article was published some 2,900 were dead. “Many wonder how this is going to end, and whether the economic cost of the lockdown is worth it. There are encouraging signs that the number of new cases in the original red zone in northern Italy may be leveling off, but experts say it is far too soon to consider this a reliable trend.” There were 2,000 people in ICUs across the country on March 18.

But what worried some was that it wasn’t clear if it was working. “Dr. Giorgio Palù, the former president of the European and Italian Society for Virology and a professor of virology and microbiology of the University of Padova, told CNN he’d hoped to see the first signs of a change after just over a week of nationwide lockdown, but that has yet to materialize. ‘Yesterday we expected to have a change after almost 10 days of this new measure … but it’s still rising,’ he told CNN. ‘So I don’t think we can make a prediction today.'”

Italy also appears to be triaging patients. One report notes “The criteria for access to intensive therapy in cases of emergency must include age of less than 80 or a score on the Charlson comorbidity Index [which indicates how many other medical conditions the patient has] of less than 5.” Nearly 13,000 of Italy’s coronavirus patients are hospitalized with symptoms, and of those, more than 2,000 are under intensive medical care, straining hospitals’ resources, NBC noted.

Something else which has concerned those following the crises is that the numbers do not fit the model in different countries. For instance in the US reports note that forty percent of those hospitalized are between ages 20 and 54. The model generally thought older people would crowd into ICUs, not younger people. In addition the virus can exist for up to three hours in the air and up to three days on surfaces that have been contaminated, according to new research. Another issue not likely taken into account sufficiently in the initial models were the number of health professionals who would have to be quarantined. In Israel by March 19, 55 medical staff members, including top doctors, were in COVID-19 quarantine.

It could be that the model was based on insufficient or problematic data, particularly data from China where there is lack of clarity on precisely what happened in Wuhan. The problem with feedback loops and confirmation bias is that it looks at what is put into the system without questioning basic assumptions. The problem facing many governments is that they only have one shot to this get this right.

There was no plan B.

Life in China “returned to normal”: The past and the future

A little noticed article, also at CNN, on March 15 claimed that life in China “is beginning to return to normal now that the coronavirus outbreak has largely been contained across the country, with lockdowns lifting and employees returning to work.” Indeed only 20 new cases were reported on March 15, “a drastic drop from just a few weeks ago, when the country was recording thousands of new infections a day.” New cases were also concentrated in Hubei, where the outbreak began, or in international traveler. Domestic travel was resuming. “During the worst of the outbreak, 1,119 highway entrances and exits across the country were closed. Now, all but two have reopened, according to state media outlet Xinhua.”

This may sound remarkably similar: “Just a month ago, much of China was essentially locked down. Many residents weren’t allowed to leave their apartment complexes, let alone the city. Some stayed indoors for weeks on end. Even within cities, public transport was restricted; in Wuhan and other locked-down cities, subway trains were halted and most taxis suspended, with only a small number of government-issued shuttles and cars operating.”

Indeed, China had supposedly done what western countries were about to do. China’s past was the West’s future.

https://twitter.com/realDonaldTrump/status/1240355985673392128

Western countries are preparing for a “war”

Of interest, many countries see this as a kind of war. US President Donald Trump says “I want all Americans to understand: we are at war with an invisible enemy, but that enemy is no match for the spirit and resolve of the American people.” In the UK: “We must act like any war time government and do whatever it takes to support our economy” says Boris Johnson. France’s Emmanuel Macron says “nous sommes en guerre.”

Benjamin Netanyahu has said that this is a struggle of life and death against an invisible enemy. Iran’s Supreme Leader says “The experience we gain combating COVID-19 and the people’s sacrifices and activities that benefit the general public, are achievements that turn tragedies and threats into blessings and opportunities.”

Is the government generating anxiety?

Israel has proven an interesting case relating to the spread of the virus. For instance the country acted very early to try to prevent any cases from arriving or isolate those cases that did. The first non-quarantined case was on February 27, there were 39 cases by March 9. Then it rose rapidly  by March 14 to 143 and 427 by March 18. Israel had initially tried to stop travelers from affected Asian countries and quarantine those who came in contact with carriers. Then it required home quarantine from those who travelled to conferences abroad on March 6, expanding that to everyone returning from abroad on March 8. This apparently had little affect because the contagion was inside the borders. By March 17 and 18 new rounds of increasingly strict guidelines were issued. People were sent home from work, government employees given paid leave. By the end of the day on March 18 the government was saying that if people didn’t heed the guidelines then a total lockdown was coming.

Israel pulled out all the stops also to track people using technology usually reserved for fighting terrorists. That could mean facial recognition or tracking phones. Those who were in the proximity of identified carriers for more than 15 minutes, or so, were sent messages from the health ministry to self quarantine. Also the Mossad sought to help bring testing kits.

But was it working? “Hebrew University professor Jonathan Huppert told The Times of Israel that generating anxiety appears to be “part of the goal” of the rules announced Tuesday, which told Israelis to stay in their homes as much as possible.”

The notion of using one policy to achieve another was part of the plan. You don’t jus lock people down to create social distancing. You need to scare them. But some were concerned that the government’s measures might not have the desired affect.  “It’s a tough sickness. It’s a sickness that needs to be fought. But we need to keep proportions,” Dr. Leonid Eiselman said. Ruination for the economy was on the way. This would ultimately hurt the health system and cause more deaths than the current pandemic, argued Eidelman

THE REAL story in Israel might have been exacerbated by lack of hospital space and a health system already stretched to a limit. Reports indicated that the early lockdown was due to the fact the health system had been mismanaged. In short the extreme measures might be designed by the government mostly to save face for the government’s own failures. This meant sending millions to a version of quarantine and using the security services most advanced methods to monitor them to evade questions about a massive failure to prepare the health system.

A report argued that “Israel is woefully unprepared for such a crisis as infections. Israel has the lowest number of hospital beds per capita than any other developed country. Israel has one of the highest mortality rate from infections than almost every other developed country (due to limited hospitals and beds which allow for infections to jump from patient to patient.) Israel has the highest occupancy rate of hospital beds than any other country. Every winter Israel is only able to cope with the simple flu virus by stacking patients in hospital corridors like cord wood.” So this may have been why Israel was acting as if it was on a war footing. 

There were also questions about how well the virus was understood. “Prof. Jihad Bishara, the director of the Infectious Disease Unit at Petah Tikva’s Beilinson Hospital, said that some of the steps being taken in Israel and abroad were very important, but the virus is not airborne, most people who are infected will recover without even knowing they were sick, the at-risk groups are now known, and the global panic is unnecessary and exaggerated,”one report noted.

What are American doctors saying? One report from the Boston area has the following language: “In the US, we have to slow down the virus. American hospitals, Boston hospitals, have limited resources. We have a fixed number of ventilators and an impending calamity on our hands…The virus is now moving explosively through the human population, spreading through respiratory secretions and 10 times more contagious that the flu or cold. Although many people will recover, about 20% will wind up with a serious pneumonia that will require hospitalization. Some will be so ill from the pneumonia that they will die. We estimate this may be 2-3%, but it is higher in Italy’s experience, partially because the healthcare system was overwhelmed so rapidly.” They advocated things like, stopping play dates with kids.

Elephants in the room: How many are infected and how many are tested

March 18 brings the following report: The disease has spread to every continent except Antarctica, infecting more than 214,000 people globally and killing over 8,700, according to data compiled by the Center for Systems Science and Engineering at Johns Hopkins University.

The problem for many trying to track the outbreak is that the data they are working off is not complete. For instance, in the US there were 8,900 cases on March 18, with 2,582 new cases and 150 deaths. As of Wednesday, March 18, 56,590 people had been tested, with about 2,000 cases pending. If you slowly increase testing while the virus spreads you likely don’t even get to see a  fraction of the cases. Since many people have mild symptoms they may not know they have the virus and will never get tested.

Other countries had low testing rates.  India, with a massive population, tested very few people. Italy, which appears to have a larger outbreak, has also tested more. Rumsfled would have wondered about these known unknowns. Oddly the US hadn’t even discussed testing with the WHO. “On January 17, WHO published a protocol from German researchers with the instructions necessary for any country to manufacture coronavirus tests,” CNN reports. By February 6 the WHO had sent 250,000tests to more than 70 countries while the US had only begun its first test.

South Korea did the opposite.  By March 15 it had tested 248,000 people and found 8,086 cases. In contrast to Italy where deaths appear to be around ten percent of those identified daily, South Korea has only 84 deaths. “Korea set up drive-through test stations, an approach only now being launched in the United States. Health officials initially focused their efforts on members of a secretive megachurch in Daegu with a branch in Wuhan, but they then broadened their reach to Seoul and other major cities,” a report noted.

Other countries excelled at testing. The UAE said it had tested 125,000 by March 15. It found 113 cases. Like Israel there were no deaths in the UAE. In Israel by March 16 a total of 8,571 people had been tested. Israel wanted to increase testing to around 5,000 a day. Overall Israel wanted to aim for the South Korean numbers of 15,000 a day but was lagging.  If Israel could reach 12,000 a day that would be good, officials suggested.

The UK was also heading to test 10,000 a day. “Public Health England confirmed Prime Minister Boris Johnson’s statements that testing would be ramped up in order for 10,000 to be tested in the UK per day against the current 5,000.”

What about the case of the village of Vo’ Euganeo in the Province of Padua in the Italian Veneto region? This town that defeated the virus? On February it had its first known case, a 77-year-old resident who became the first person to die of COVID-19 in Europe. It was locked down on February 22. Mass testing began. The town was tested twice. Those who tested positive were isolated. “It proved successful when, two weeks later, the infection rate was 12 times lower than it was at the start, according to la Repubblica. At the beginning, three per cent of the population had COVID-19. Two weeks later, only 0.25 per cent did.” The village test case of several thousand people could be a model for other places. History shows that so far it may not be.

Of course, keeping people in a large pen with the virus doesn’t always work. On the cruise ship Diamond Princess.  Quarantined beginning on February 3 with 3,000 on board, the last passengers were not let off until March 1. An initial few cases eventually spread to 712 passengers and 7 died. “The difference between the two was that health chiefs in Vo’ Euganeo were one step ahead of the virus, testing everyone even if they didn’t show symptoms.”

Many are already sick but most deaths are among those with prior illnesses

A report notes: “The Rome-based institute has examined medical records of about 18% of the country’s coronavirus fatalities, finding that just three victims, or 0.8% of the total, had no previous pathology. Almost half of the victims suffered from at least three prior illnesses and about a fourth had either one or two previous conditions.” Ninety-nine percent of those who died had other problems.

That means that most of those who will die have other conditions. Bloomberg notes “More than 75% had high blood pressure, about 35% had diabetes and a third suffered from heart disease.”

We don’t know what we don’t know

• We don’t know how many people have the virus because the whole world has not been tested and cannot be tested. The cases in some countries such as India or Egypt, or in Syria and some Sub-Saharan countries may be higher than known. In places like Yemen people may be dying and it is ascribed to their pre-existing conditions. In fact, death rates from this virus are so low among younger people that in societies where most people are young the virus would go unnoticed even if it were allowed to spread. Iran, however, attempted to simply allow the virus to spread and has faced some difficulties at home because of its failure to tell the public about the crisis in February. Dozens of MPs in Iran and officials were infected. Some died. Estimates are that Iran’s official numbers of 17,000 infected and more than 1,000 dead are too low. It may be five times higher.
• We don’t know what affect lockdowns will have on the economy. As countries close borders, as the EU did on March 18 and the US did with Canada the same day, it  is not known what the affect will be on international trade and economies. Already stock markets are severely affected. Estimates sho that first and second quarter growth will stop and economies will shrink. Will they shrink by a few percent of up to 15%. One headline says the virus will bankrupt more people than it kills. If the 18-month story is correct economies could grind to a halt and the overall outcome could be ruination for years and a ripple affect for a decade.  Airlines and major industries will cease to function. It’s not entirely clear how you produce food and basic goods if  you lock down countries. Is the assumption that third world countries simply suffer the virus to feed the global north?
• How did China bring new cases to zero? China reported no new cases on March 18. How is that possible even with the models of “flattening the curve”? It doesn’t fit. The models the West is working off show numbers declining and the problem that when suppression is relaxed the numbers will increase again. China appears to be saying it has defeated the virus entirely.
• Why are death rates so low in South Korea and high in Italy? The number of deaths in South Korea is so low that there is no reason hospital ICU capacity would be overwhelmed. In fact South Korea only has around 60 serious or critical cases. That is manageable. So perhaps the lockdowns are not as necessary as models predict, if the South Korean cases is more normal than the Italian case? This is what lacks clarity because it is not clear why death rates are so low in some countries. It is also not known if total testing will show that large numbers of people are not affected.  Various theories about “herd immunity” have not been tested either.
• What happens in the global south, in countries that due to their weak health systems and inability to control most of the population will have to go down the “do nothing” road of the model. There is no evidence that countries such as Nigeria can test their entire public or lock it down. Some countries have insurgencies or are unstable. Much of the Sahel is made up of non-governed spaces. If and when the virus gets there, there won’t be anyone to assist. Western states that often provide charity, NGOs and capacity to these states are locking themselves off.  So the global south is on its own against this virus. But letting the virus play itself out may illustrate that actually a weak and vulnerable health system can survive the pandemic, especially when the system is already used to the fact that it does basically triage, only treating some people. Countries that face widespread illnesses or malaria and other problems, will simply have to move on with this.
• Democracies are afraid. Democracies are instituting undemocratic and authoritarian methods because they fear what the public will do if they reveal the failures in their health systems. This may underpin why western countries prefer a lock down to tough questions. Western states are fragile and populism has been rising. With mass immigration many western governments began to realize that far-right and far-left movements risked the neo-liberal order that was built up after 1945. This virus could be a nail in the coffin of that order. It is something that western governments fear and it is being channeled into their decision making which also amounts to triage. In this case triage is meant to save the government and cut off things like the economy. But the long term disaster of destroying the economy will have the same result as the shorter term pandemic. Most countries likely cannot be locked down for months or years and not see civil disobedience. Some of these countries already have major law-and-order problems, such as a wave of “gang” related bombings in Sweden, or riots in France. Once the shock and fear of the virus evaporate, people may begin to ask questions and rebel. A constant state of crisis, or “war” can keep them distracted for a while.
• The various models out there, from China to Iran, Italy and Israel are not welcoming. None of them provide a silver bullet. This will leave governments scrambling to make the next decision. But many acknowledge there is no Plan b.

 

The author of this post has been tracking the coronavirus outbreak since it began, he is the executive director of The Middle East Center for Reporting and Analysis (MECRA) where he has kept a daily update of cases and developments in the Middle East. He was among the first to identify the Iran crisis with the virus and wrote articles about it at The National Interest and National Review. He has also documented Israel’s response at The Jerusalem Post and The Spectator. He has spoken to CBN News and others about the crises. His work on the coronavirus threat in the Middle East has been referenced in other publications as well.

Frantzman is the author of After ISIS: America, Iran and the Struggle for the Middle East (2019), and writes for Defense News and other publications. he holds a PhD from The Hebrew University of Jerusalem and is a former assistant professor at Al-Quds University.