Making Sense of COVID-19* (20.03.20)

This article is dedicated to the heroic acts of ordinary citizens — including all medical professionals on the frontline; scientific and medical journals enhancing our knowledge of epidemiology; biopharmaceutical researchers; public intellectuals who actually understand risk and advocated pre-emptive precautionary measures; grocery store employees; community volunteers; cleaning staff; and every single person who is adhering to social distancing protocols and, in doing so, flattening the curve and saving lives.

Introductory Remarks

I write these words from the pseudo-cocoon of the eye of this pandemic storm. However, in the words of Dr Michael J. Ryan, Chief Executive Director of the World Health Organisation’s Health Emergencies Programme, in these unprecedented times “perfection is the enemy of the good…speed trumps perfection”. Time is of the essence.

In an attempt to make sense of all this, I have sought to identify the epistemic and psychological factors and cognitive biases that contributed to our initial inability to fully appreciate the gravity of the pandemic and to act accordingly; the importance of acting now; and the potential future implications and opportunities emerging from this paradigm shifting moment.

1. Cognitive Biases

Via Negativa

If we all practice via negativa, lives will be saved. The curve will be flattened. Via negativa is the idea that omission — refraining from doing something — can be optimal. We live in a society that rewards output. The CEO’s bonus is dependent on an increase in share price rather than the avoidance of corporate catastrophes. In general, we are predisposed to favour action over inaction because it is hard to point to harm avoided. Within the context of COVID-19, your inaction — staying at home and maintaining social distancing protocols — can save lives.

“It’s easy to get people to come together in common sacrifice in the middle of a war. It’s very hard to get them to do so in a pandemic that looks invisible precisely because suppression methods are working. But that’s exactly what we’re going to have to do” — Jeremy C Young

I have seen labels like ‘hysterical’ and ‘paranoid’ thrown the way of people who advocated pre-emptive precaution weeks in advance. Unfortunately, these people are succumbing to the Overreaction Paradox, whereby the result of taking effective action (i.e. social distancing) is that nothing happens. James Clear notes that this makes the effort seem unnecessary and like an overreaction, even if it was the right thing to do. As Alex Tabarrok poignantly observes, “if six months from now people say ‘we overreacted, that it wasn’t as bad as people said it was going to be’ then we will know we were successful”. This is the via negativa in action.

In the words of Nassim Nicholas Taleb and Joseph Norman:

“Precautionary decisions do not scale. Collective safety may require excessive individual risk avoidance, even if it conflicts with an individual’s own interests and benefits”.

That latter sentence might sound like a Soviet Union call to collective solidarity in the face of unnecessary hardship. However, not only is our current hardship unavoidable, the welfare of the individual is intrinsically tied to the welfare of the collective — even if not directly so, initially. For most young people, the threat probably seems too abstract for them to truly have an appreciable vested interest. But if — although hopefully not, when — you lose a loved one to COVID-19 (based on statistical probabilities, this is likely) then your interest becomes vastly more vested. Your future self will judge you for the actions you take today. Again, in the words of Taleb and Norman:

“one must “panic” individually (i.e., produce what seems to an exaggerated response) in order to avoid systemic problems, even where the immediate individual payoff does not appear to warrant it”

You may feel obliged to “do something” to contribute to the cause but honestly, the most ethical thing you can do is: nothing (there are obvious exceptions for working professionals). This is the inverse of the call to heroism our ancestors experienced. Be the hero and refrain from physical interactions (whilst maintaining social connection and well-being).

Experiential, non-linear growth

“The greatest shortcoming of the human race is our inability to understand the exponential function” — Albert Allen Bartlett

Crude summation: in a linear system, output is directly dependent upon input. In a non-linear system, output is a limitless factor of input, meaning that small changes in input can lead to sudden and disproportionately large changes output. A few people infected with COVID-19 can be the root cause of an epidemic in a very short space of time, as new cases more than double each day.

When the Chinese Centre for Disease Control and Prevention started publishing the number of cases in late January, the rest of the world had a full month to pre-emptively act. We didn’t. Initially the likes of South Korea, Italy and Iran paid a heavy price. The same exponential growth that occurred in Wuhan, Hubei and other Chinese regions was reflected in these aforementioned countries before the end of February. The same thing is now happening in Spain, Ireland, the UK, the USA and elsewhere.

People succumbed to the fallacy of naïve empiricism when they compared the non-linear, exponential COVID-19 data vis a vis data that was constrained by linear growth. It’s simply not possible for car accidents or deaths by obesity or the flu to double every day, continuously, for a week.

I appreciate that Donald Trump isn’t exactly a bastion of rationality or intellectualism but he is the President of the United States and this kind of thinking pervaded much of the initial ridicule concerning the warnings being sounded about COVID-19. It seems extraordinary to think that was as recently as 9 March 2020. In addition — and as was rightly pointed out — given that 40 million people caught the flu in 2019, 37,000 deaths equals a <0.1% mortality rate; on the other hand 22 deaths out of 546 detected coronavirus cases equates to a 4% mortality rate (40 times greater).

The other problem with instigating voluntary individual precaution is that the risk of a car accident or the flu is usually greater for an individual than it is for society; whereas the risk of COVID-19 is greater for society than it is for an individual (although these probabilities will eventually converge if each individual does not act so called ‘irrationally’ by limiting their behaviour).

The Pareto Principle

The Pareto Principle is a natural phenomenon evident in most aspects of life. It shows that a small proportion of something accounts for a disproportionately large effect. It is also known as the 80/20 rule e.g. 20% of workers account for 80% of the work in an organisation. In reality, it’s often more of an extreme split, like 95/5. The point is that once we are able to establish and identify the causation behind the spread, it’s likely that a small minority of COVID-19 carriers will be responsible for the vast majority of transmissions. The reason every single person has an absolute obligation to the rest of society is evidenced by the case of Patient 31 in South Korea. This was the first documented case of a “super-spreader”. South Korea had initially contained the virus within its first 30 cases. Patient 31 was a super-spreader who passed it to 1,600 other people after attending mass at her local church and a buffet lunch at a hotel.

The map is not the territory

The map of reality is not reality itself. Maps and graphs are reductions of what they represent. COVID-19, sadly, is a prime example of this. On 22 January the city of Wuhan thought it had 444 cases, when it actually had 12,000 (27 times more). Based on live statistics, Tomas Puyeyo has suggested that we can calculate the true number of cases in an area (rather than the confirmed cases) by multiplying the death rate by roughly 800.

Take Ireland as an example. Based on WHO statistics, as of 19 March 2020 there were 2 deaths and 292 confirmed cases. However, the true number of actual cases is likely >1,600. This might seem relatively small until you factor in the exponential growth of the virus. The asymptomatic nature of COVID-19 makes our statistical maps all the more uncertain. The map (reported cases) is not the territory (actual cases).

Absence of evidence is not evidence of absence

Many people dismissed the seriousness of the virus because there were a lack of positive cases showing up. This was fallacious on a number of grounds. Firstly, just because there is no evidence of something doesn’t mean it doesn't exist. Secondly, there was/is a lack of testing in many countries. The countries who seemed worse affected were often only so because they had better testing measures in place (China, South Korea). There was a complicated, almost inverse relationship between testing and the public perception of politicians. Not testing was a form of burying one’s head in the sand and spinning preferential narratives. Initially, realpolitik took precedence over the welfare of the citizenry, but viral epidemics have no regarded for political cover-ups. The truth eventually emerged.

Optimism Bias

“The death of one person is a tragedy. The death of a million is a statistic”

Optimism bias causes someone to believe that they themselves are less likely to experience a negative event. When COVID-19 was emerging in China, it seemed distant and irrelevant to many in the West. This is because we prioritise contextualised thinking over abstract statistics. Our prioritisation of information and data becomes distorted by a preference for the immediate. Despite the exponential growth we saw emerge day after day, it did not shake us into action. The uncertainty and randomness of the unfolding situation was too abstract for us to tangibly conceptualise as a soon-to-be real threat to us personally.

Second-Order Thinking

The second and third order consequences — all the more pronounced in our age of globalisation and interconnected supply chains — are what render modern events far more catastrophic than any predictive model can account for. Fortunately, there will likely be many positive second order consequences arising from this pandemic, such as:

§ accelerated focus on biomedical technology;

§ introduction of biological passports;

§ improved hygiene practices;

§ greater spending on pandemic defence and preparedness for future pandemics;

§ (hopefully) a decisive end to the “anti-vaccine” movement;

§ a temporary reduction in pollution and CO2 emissions;

§ endless opportunities for start-ups and entrepreneurs.

However, the more immediate second order consequences are clearly negative:

§ finite resources of healthcare system being devoted to COVID-19 resulting in trauma operations, cancer treatments etc being halted; additionally, brutal triage decisions will have to be made (“after a few days, we have to choose…not everyone can be intubated. We decide based on age and state of health” — Christian Salaroli, Italian MD);

§ global economic recession;

§ bailout of multiple industries;

§ job losses;

§ small businesses closing due to cash flow issues;

§ resources being redirected away from key services eg. mental health, homelessness, NGOs etc

When we are considering our responses to the pandemic we must consider the second, third and nth order consequences. This begins with the question: “And then what?”.

2. The Importance of Acting Now

Despite positive news emerging from many countries in Asia, it will get worse before it gets better in the West. On 16 March 2020, Imperial College London released a study titled ‘Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand’. This study plugged infection and death rates from China, South Korea and Italy into epidemic modelling software and ran a simulation[2]. If the US does absolutely nothing, then 80% of Americans would get the disease and 0.9% of them would die (364,000), with 4–8% percent of all those over the age of 70 dying. This doesn’t account for the second-order consequences, most of all an over-run healthcare system. Imperial College found that if social distancing protocols were adhered to, the death rate would have halved. Read that again.

Finally, the Imperial College team ran the numbers assuming a “suppression” strategy, which means:

§ isolating symptomatic cases;

§ quarantine their family members;

§ social distancing for the whole population;

§ all public gatherings/most workplaces shut down;

§ schools and universities close.

If these were strictly adhered to, the death rate in the US peaks in three weeks but ‘only’ at a few thousand deaths, and then it goes down. These numbers in ICU would not exceed the capacity of available ventilators either.

This is a very insightful epidemic calculator where you can adjust scenarios and see what the likely outcomes will be based upon how quickly we act. The range of death tolls, depending on the variety of containment measures we implement (or don’t), is scary.

3. A Word on the UK’s ‘Herd Immunity’ Strategy

The UK’s ‘herd immunity’ strategy is likely to go down as either one of the greatest social experiments in history — or, more likely, one of the most negligent and crass bets that led to the death of hundreds of thousands. Maybe even millions. I reserve my judgement (and I hope beyond hope that I am wrong) but my initial reaction was that the potentially high rewards were outweighed by the immensely high risks. I cannot see how the means will justify the ends. Their rationale was i) future immunity and ii) avoiding ‘behavioural fatigue’, two concepts based on questionable, theoretical “science”.

We are still awaiting the publication of the models and assumptions the UK government used as the basis for their ‘herd immunity’ strategy, but reports have suggested that the UK was basing its policy on a model based on hospitalisation rates for a different disease. In the words of Akiko Iwasaki, a virologist at the Yale School of Medicine, “you don’t rely on the very deadly infectious agent to create an immune population”.

(I endeavour to practice what I preach — I flew home from London a week earlier than my departure date from a secondment in the city, such was my aversion to being a participant in this rogue experiment).

On 3 March 2020 Jeremy Warner, assistant editor at The Daily Telegraph, wrote:

“Not to put too fine a point on it, from an entirely disinterested economic perspective, the COVID-19 might even prove mildly beneficial in the long term by disproportionately culling elderly dependents”.

This coldly mechanistic, Social Darwinian viewpoint espoused may be a more nefarious example of the rationale which might have fueled such a strategy, but beyond the inhumanity it evidences a general deterioration in our attitude to our elders — and ancient wisdom more generally. Our modern hubris has resulted in a loss of respect for timeless principles. In the words of Taleb, “elders are repositories of complicated inductive learning”.

4. Future Implications

Climate Change

“If there is a silver lining to the COVID-19 pandemic, it is what it might mean for the climate crisis. Not only have attempts to control the virus led to a reduction in carbon emissions, they have also led to a significant shift in the way individuals, institutions and politicians discuss our responsibility to protect vulnerable groups in our society” — Professor Anne Orford

The positive measures that emerge from our attempts to contain this pandemic could act as a potential blueprint for reframing our policy approach to our impending ecological destruction. In the words of Zach Bush MD, “when we separate ourselves from nature and destroy our diverse ecosystems, nature’s system of checks and balances kicks in”. Mother Nature keeps the score.

Unfortunately both climate change and pandemics are hindered by the ‘Tragedy of the Commons’. The Tragedy of the Commons is a situation in a shared-resource system where individual users, acting independently according to their own self-interest, behave contrary to the common good by depleting a shared resource. Unless people collaborate, each individual theoretically derives more personal benefit by acting selfishly. Independent of ethical consideration, it would be rational for an individual to pillage the natural resources of the earth as this would lead to commercial gain; but if everyone adopts this attitude, it becomes an unmitigated disaster for the resources of the ‘commons’. Similarly, when people only think for themselves and bulk buy food items it leads to food shortages — and risks anarchy. We need to appreciate that acting in collaboration with one another is a more advantageous long-term strategy than mere self-interest, within the context of Game Theory.

Complex systems

Our world is governed by chaos dynamics, whereby small changes in initial conditions can have disproportionate downstream effects. This phenomenon is called the butterfly effect. COVID-19 has evidenced just how complex our systems really are, and the fact that many of the risk models we use are outdated and/or deficient. These are traditionally based upon the Gaussian, normal distribution bell-curve. Here, the extremes are predictable. In the real world, time and time again we have witnessed how there is no real cap to extreme outliers. The events which have shaped the 21st century — 9/11, the 2008 financial crisis, and to a lesser extent the Brexit and Trump elections — were completely outside the scope of these predictive models.

In the words of Carlo Rovelli:

“We have a hundred billion neurons in our brains, as many as there are stars in a galaxy, with an even astronomical number of links and potential combinations through which they can interact. We are not conscious of all of this. ‘We’ are the process formed by this entire intricacy, not just by the little of it of which we are conscious”.

We are only conscious of an infinitesimal portion of how society functions, not to mention the complexities of our biology and the idea that something invisible to the naked eye could be attacking our immune system. Our brains are incapable of fully comprehending such complexity — much of the world is composed of random, non-sequential, non-ordered events. Hence, it is to some degree understandable (albeit not intellectually admirable) that we choose to outsource our thinking to authorities, whom we hope can consolidate all of this complexity and provide us with simplified answers. Immanuel Kant’s doctrine of autonomy states that we cannot accept the command of an authority, however exalted, as the ultimate basis of ethics. Whenever we are faced with the command of an authority, it is our responsibility to judge whether the command is moral or immoral.

As an antidote to this propensity for outsourcing, we need to encourage greater thinking from first principles. Reasoning by first principles involves breaking down complicated problems by subjecting our assumptions to stringent testing. We actively seek to “falsify” our hypotheses. It guards against ossified thinking. COVID-19 has reminded us of the importance of cultivating independence of mind and thought. Taking ownership of our own thinking process won’t reduce the complexity in the world but it will provide us with greater leverage, independence and adaptability in a changing environment.

Benoit Mandelbrot coined the concept of fractals. Mandelbrot showed how geometrical figures in nature had the same characteristics as their whole; they were merely progressively smaller scale versions. What this experience has shown us is that, in addition to having individual immune systems, civilisation also has a collective immune system. We ought to view this experience as a test of our immunity. COVID-19 is the proverbial canary in the coal mine. It has revealed the hidden fragilities in our systems. No system is perfectly reliable, so we need to build backup mechanisms in order to protect the integrity of the whole. For example, COVID-19 has exposed our global supply chains and the weakness of its “just in time” inventory model. A mere two weeks of economic shutdown have led to shortages across the supply chains. We also need to diversify where we source our materials from — China enjoys a monopoly on many key components and materials for the rest of the world. This provides them with immense leverage if an adversarial relationship exists at the time of a crisis.

Politics

“Pandemics turn us all into socialists” — Paul Bloom

It is clear that this pandemic has, more or less, transcended politics (thankfully). I even saw Ted Cruz retweet Alexandria Ocasio-Cortez. I am not commenting on what political system is right (I believe in some sort of hybrid), but this pandemic has reinforced the utility of the welfare state, particularly in times of crises. The irony is that, at least in the US, the capitalists who deride state-sponsored healthcare and education are now calling for a bailout of the airline industry because “the free market” has rendered them bust. This pandemic has also evidenced the power of decentralised decision making and autonomy. The worldwide rise of “localism” continues as a replacement to the top-down heavy “globalism” that has pervaded since the Thatcher/Regan movement in the 1980’s.

Regardless of the macroeconomic outcomes, COVID-19 is accelerating many progressive economic policies. Sadly, it may take these tragic circumstances for the United States to collectively realise the importance of a functioning public healthcare system. Andrew Yang’s campaign for the Democratic nomination ran with universal basic income as its foundational policy. Yang’s whole campaign has been vindicated in the last few days following Mitt Romney’s proposal to send cash to every US household. Hong Kong awarded $1,280 to its residents whose finances had been hit by the spread of the virus. The Irish Government are now offering an emergency unemployment payment for up to 6 weeks.

To avoid this article spanning tens of thousands of words, I wish to very briefly address some other issues COVID-19 has raised. There may be scope for further exploration in later discussions:

§ Veganism — whilst the factors that ultimately led to the spread of COVID-19 were multivariate, what cannot be overlooked is that the original transmission to humans came through the consumption of non-human animals. Our food choices have ethical, environmental and now public health implications. Veganism is increasingly becoming a modern imperative.

§ Independent on what kinds of food we eat, we need to review the chemicals and pesticides that are permitted to be sprayed industrially on our food. Zach Bush MD has presented fascinating evidence showing the very strong correlation between glyphosate spraying and cases of COVID-19 in Eastern China.

§ Was this a bioweapon? Was this a conspiracy theory by the Chinese Communist Party to cripple the West? Logically — no. Think Hanlon’s Razor (never attribute to malice that which is adequately explained by incompetence or ignorance) and Occam’s Razor (among competing hypotheses, the one with the fewest assumptions should be selected i.e. the simplest solution is most likely to be the correct one). Anecdotally — no. On the Joe Rogan podcast Michael Osterholm, an internationally recognized expert in infectious disease epidemiology, stated that there was zero evidence of this being a case of biowarfare.

§ We need to remain vigilant about any encroachment of civil liberties beyond what is absolutely necessary to contain the pandemic. The US government infamously enacted emergency legislation (called The Patriot Act) immediately after 9/11, which permitted mass state surveillance of private citizens. Already in Ireland we have seen the passing of The Health (Preservation and Protection and other Emergency Measures in the Public Interest) Act 2020. It bestows significant powers to the State. For example, Section 38A permits certain medical officers to order, in certain circumstances, the detention of persons who are suspected to be possible sources of infection of Covid-19.

§ Big Pharma narratives — in recent years there has been a growing public consensus lambasting the business model of ‘Big Pharma’. This trend reflects a similar public U-turn on the once holier than thou ‘Big Tech’ companies (Google, Facebook, Amazon, Microsoft, Apple). Yet life is a composite of hazy, grey areas. It is rarely black or white. Rarely do we find someone or something 100% good or bad. Yes, there are specific examples of certain pharmaceutical companies grossly exploiting situations, most notably Mallinckrodt’s role in the opioid crisis in the United States. But COVID-19 has reminded us of the good that pharmaceutical research & development can bring to society through the discovery of new vaccines. Here’s hoping they can use their collective strength to find the antidote to COVID-19 asap.

§ The demise of the mainstream media continues — new sources of media are continuing to emerge and provide citizens with primary, open source information. Tomas Pueyo’s seminal article on COVID-19 received over 40 million views in one week on Medium.com. Tomas is an engineer out of Silicon Valley. The dissemination of information is being democratised and diversified beyond the institutional vanguards of old.

Concluding Remarks (Reasons for Hope)

“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change” — Charles Darwin

These last few weeks have been surreal for everyone. Observing the fallacies exacerbating it’s spread and the immediate inaction of authorities has been disconcerting and frustrating. I feel an epistemic responsibility and a moral duty to put forth the cognitive tools I found useful whilst observing the real-time feedback loops that were reinforcing the predictive analysis of trends emerging in China, Asia and Northern Italy, while a minority of brave public intellectuals were sounding the alarm — to mostly dismissive retorts. I hope that these cognitive tools can contribute to containing COVID-19 and avoid similar errors in the future. It may come across as ‘hysterical’ or ‘paranoid’ to some of you but I don’t care at this moment because the stakes are too high. Over-reaction must be our default position in this unprecedented time. It will save lives. I cannot stress this enough.

Adjustment disorder describes a situation whereby people struggle to come to terms with the reality of a significant change, and it may be that many people are still coming to terms with the gravity of this unfolding situation. Irrespective, I think the reactions of the majority of people (at least here in Ireland) has been exemplary and the collective solidarity shown should be commended.

It’s understandable that — as a kind of coping mechanism — people are talking about when they can return to ‘normality’. But I think such sentiments miss the point of this whole experience entirely. COVID-19 represents a form of plasticity, not elasticity. We cannot return to our original, pre-pandemic state. The coming weeks and months represent an extraordinary opportunity to reset and reorient our society. Not in a utopian, ‘blank slate’ type of way but as an evolutionary process whereby we discard what no longer serves us, collectively and individually, and upgrade the tools that we use to navigate this complex existence.

“No problem can be solved from the same level of consciousness that created it” — Albert Einstein

This virus has had the unintended consequence of reminding us of our shared oneness and interconnectedness (whether you prefer to view that through an ephemeral soul or atomic particles — both equally awe inspiring in my opinion). We have an obligation towards humanity as it currently exists, and to any future iterations of our species. We must act now, in solidarity. Act as if you already have the virus and do everything in your power to stop its spread. Stay at home. This is our call to action.

Brian Cronin (20.03.20)

*In this article I use the technical term for the coronavirus disease, COVID-19, which itself is a member of the Severe Acute Respiratory Syndrome family. My learned friend Ciaran O’Regan (who wrote a fantastic article himself) uses the term ‘Wuhan Virus’ as an act of solidarity for the people of Wuhan and — in particular — Dr Li Wenliang, who was the first whistle-blower who attempted to inform the wider world about the outbreak of this virus. Dr Li ultimately died soon after.

∞ If you have anything to add or simply wish to convey feedback, please feel free to drop an email brian.t.cronin33@gmail.com

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