1 AC: The counsel of canaries

It’s not that we can predict bubbles – if we could, we would be rich. But we can certainly have a bubble warning system.

Richard Thaler

We have just completed Year 1 AC – After Covid. Clearly, we don’t know all we need to know. Conversely, we are awash in data and probably know more – collectively – than we think we do. In this series of posts, I’m presenting my observations, preliminary conclusions they’ve led me to, and what might be a better approach to future pandemics and other disasters. Of necessity, this will be focused on the US experience; sadly, these observations seem to apply to the rest of the Western world as well.

Early detection is a key to avoiding or at least successfully managing a crisis. Whether it’s the approach of a superstorm or the imminent bursting of an economic bubble, early detection buys time so that we can better respond. One of the most important questions about the pandemic is – why didn’t the US public health bureaucracy respond more rapidly to the crisis. My answer: lack of a canary.

During most of the last century, coal miners took a pair of canaries into coal mines to act as an early warning system for the buildup of toxic gases. If the canaries stopped singing or died, the miners would exit the mine as rapidly as possible (Canaries were chosen because they are easily portable and like all birds are very susceptible to changes in air quality.*).

As late as March, CDC spokespersons (e.g., Dr Fauci) were reassuring Americans that there was no reason to make drastic changes in their lives: “If you are a healthy young person, there is no reason if you want to go on a cruise ship, go on a cruise ship” (March 9, 2020). Throughout the first three months of the pandemic, the CDC seemed to echo the World Health Organization (WHO) in downplaying the severity of the outbreak. In effect, it appears that we were using the WHO as our canary, oblivious to the potential for bureaucratic bungling (or worse) on their part.

Contrast this with Taiwan’s CDC. In December, their monitoring of online sources indicated that there was an unusual outbreak of pneumonia in Wuhan Province, China. They sent an urgent email to both the WHO and the Chinese CDC probing whether there was person-to-person transmission. At the same time, they advised the Taiwanese government to begin screening all passengers entering the country from China. This was accomplished December 31, 2019, one month before President Trump’s Executive Order mandating similar actions. As a result of their vigorous and early action, Taiwan has had only 10 deaths from the virus – 0.00000042 deaths per capita. Contrast this with the US rate of 0.00166 deaths per capita, or 551,005 in total (as of 3/31/21).

According to Dr Deborah Birx in a recent interview, ~100,000 deaths were due to the initial surge. While we will never know how many lives might have been saved if the US had acted sooner, it seems to be inarguable that tens of thousands would not have died. That’s the price we paid for not having a canary.

I am clearly not a health professional, but it seems clear to me that we need a better early warning system for health crises. Taiwan was motivated by the bitter lessons learned from SARS and H1N1; we can only hope that covid-19 serves as the same wakeup call for our public health system. The question then becomes how do we develop one.

There are a few analogues available. The meteorological community, for example, over a long period of time has actively sought to extend the time between warning of a tropical storm and its actual landfall. Their success is largely based on historical patterns incorporated in mathematical models, coupled with sensing data. A key factor to their success so far has been continuity of effort – updating their approaches with data storm by storm. The earthquake community is trying to do the same thing, with increasing success, though relying much more heavily on sensor data. The economic community (as noted in the quote above) continues to expend a great deal of its research effort on looking for canaries that portend economic crises. This is a somewhat more difficult challenge but even here historic patterns of events are providing hints of impending economic disasters.

It does not appear that the health community, at least in the West, has taken the same approach. As I’ve mentioned in previous posts, the health community has developed mathematical models, but they seem to be modeling the spread of contagion rather than focusing on providing early warning (I’ll be thrilled if my observation is proven incorrect!).

Sun Tzu in The Art of War said that the best battle is the one never fought. The best way to avoid a pandemic is to detect contagion as early as possible, and then rapidly take steps to mitigate its effects.** Canaries saved the lives of hundreds of coal miners last century. The thousands of lives lost during the initial surge attest to the fact that we urgently need to develop an effective early warning system for health crises in this century.

* Developing this approach was just one of the accomplishments of John Haldane, a Glaswegian professor and technologist. He also invented the first respirator as well as the decompression chamber for divers.

** The FDA and CDC bureaucracies also bungled the early response. Derek Thompson of The Atlantic has an excellent article detailing this.

Once the parties start again

We’re now in the third month of dealing with the coronavirus pandemic in the US. In some ways our collective response to this has been effective (e.g., closing the borders), in some ways not (e.g., politicizing the pandemic). We are clearly learning as we go – as we should – and our response efforts are getting better focused. But the pandemic is both causing problems that will last long after we have the pandemic under control, as well as shining new light on existing problems that we haven’t solved.

Taiwan has done exceedingly well in dealing with the pandemic. Even though next door to China, only two deaths have been reported so far (By comparison, Italy’s per capita death rate from the virus is almost 1000 times higher.). Taiwan’s success is due in large part to their taking a hard look at their response to SARS in 2004. They built a crisis plan based on what they learned and have successfully implemented it. Their approach to the crisis has been different from ours and other countries (See here for a nice summary article and to get to a list of the actions they’ve taken.). I hope we in the US will do the same after this crisis passes. In this post, I want to pose some questions that I hope will be considered (starting with gathering appropriate data). I’m focusing on impacts to our communities; there are many others that need to be considered as well.

What is the “aim point” for our response in the future? The current strategy in the US is aimed at limiting the number of deaths from the virus. Thus, we’re not really trying to prevent the virus from occurring; rather we’re accepting that people will catch the virus but trying to slow down its spread. If we are unsuccessful, then people will needlessly die because we don’t have enough ICU hospital beds, respirators and ventilators to treat the potential spike in cases. If we had a cure OR a vaccine OR more hospital beds and needed equipment, we could potentially employ a different strategy.

How will those who live in cities and those in rural areas do? I must admit I have often been bemused by our country’s lurch toward urbanization. Cities concentrate risk – you’re more likely to be exposed to the virus if you live in a city (New York City is currently experiencing a death every hour.). Conversely, cities also concentrate resources – there are more hospitals, medical equipment and medicines in cities to deal with the sick. In the Spanish flu epidemics of 1917-19, mortality was less than 1% in urban areas (probably due to partial immunity from previous influenza outbreaks) compared to up to 90% in some rural communities. Right now, we have too few ICUs in rural communities and too many cases in some of our cities. We need to recognize that rural and urban health care needs are different and develop better means to address both. But to do that we need to have a better handle on what those needs are.

How will the homeless fare? Most of the permanently homeless are in poor physical and mental health. Most of them are men. Drugs, alcohol, and poor environments have compromised their immune systems. They are likely at high risk. I’m fairly certain that our communications with the homeless are – at best – spotty. We need to consider what actions we ought to take to both communicate with and care for this slice of the homeless population.

How useful were our models of the virus’ spread and mortality? As George Box famously said, “All models are wrong, but some are useful.” Our models for the spread of a pandemic are generally pretty good BUT like all models their accuracy depends on their input parameters. The ones we’re using are based on the Chinese experience, or what they’ve indicated was their experience. We don’t know how well that translates to American demographics or the American health care system.

Is the approach we’re taking to social distancing the best overall? Taiwan, South Korea have taken a different approach to achieve the same ends as our draconian shutdowns of businesses and schools. While our approach may be best for containment of the virus, we need to know how it impacts other aspects of community life, e.g., businesses, education and other social facets. We are taking action to determine the impacts on small businesses and the economy at large; we need to have the same urgency about the pandemic’s impacts on our kids’ education and our communities’ social fabric.

Can we track contacts more effectively? Tracking the contacts of those potentially infected is a key part of the strategy followed by Taiwan. This is much harder to do in our country with its patchwork of health departments at community, county, state and national levels. But I’m sick and tired of hearing the phrase “community spread” as a sort of code for “we don’t have a clue how Grandma was infected.” We can do better, but it will require that each of us takes a hard look at the balance between individual privacy and community health security.Along those same lines, we need to begin using Big Data techniques to determine potential future hot spots. There is all sorts of data indicating people flows; we need to start using them for future casting. We undoubtedly will initially stumble – make bad calls – but we can’t do better unless we start doing.

How should we deal with those crossing our nation’s borders? Our immigration policy – such as it is – is a mess. Was and is, but we need to fix it for the future. Further, many of us Americans (like She Who Must Be Obeyed) have a lot of unsatisfied wanderlust. The government took what appears to be appropriate and relatively effective action to selectively close our borders but it is clear that foreign visitors or returning Americans triggered at least some of the hot spots. While I hate to contemplate it, we need to consider actions such as required medical screening at every border entry for anyone coming into the country.

This is a difficult time for all of us. The approach we’re taking toward the virus in the US is the one most likely to deplete our social capital, at least for a while. As I’ve often said, never underestimate the power of a party – I hope the human love of partying will help us to recapitalize our social infrastructure. But once the parties start again, we need to look back honestly at the crisis past, and be better prepared for the next one – knowing full well that it won’t be like the last one.

In my next post, I’ll turn from crisis planning to putting together a plan for coming back. Given our approach to the pandemic, what sorts of things ought to be considered in planning for our communities’ recovery?

One more thing. With all of the guidance on hand washing and use of sanitizers, we tend to overlook the obvious: healthy people are going to fare better than those who aren’t, no matter their age. All of us need to find ways to keep fit while we’re isolated. During the week, I’m usually out by 630am walking 3-4 miles. Others are using video exercise or tai chi classes. Whatever you do, please make sure you, your elderly parents and your kids find ways to stay active even while avoiding unnecessary contacts.