Five months have passed since the Wuhan outbreak. Although no cure is in sight, we have had the opportunity to learn from the successes of some, and the failures of others. While the battle is still raging, the following might be the top six factors that made the difference between success and failure until now.
1. Pills don’t work in pandemics, people do. In the absence of an effective antiviral agent or vaccine, the fast-spreading and lethal Covid-19 has troubled even the wealthiest nations. Recent experience however suggests that the presence of a well-established public health system that reaches deep into the grassroots level is more crucial than financial prowess. Kerala and Sri Lanka are examples, where a well-oiled machinery and established chain of command ensured that the orders given by the department of health were actually carried out on the ground.
Testing, contact tracing and isolation is painstaking work, requiring competent ground-level support. Several developed nations including the US and UK who had state-of-the-art hospitals and research facilities could not match the old-fashioned person-to-person healthcare worker teamwork that silently kept entire communities safe in these areas.
2. Timing is everything. Early assertive action has saved many nations, especially resource-limited countries such as India, Vietnam and Sri Lanka. In a pandemic where the spread is exponential (the time taken for 10 cases to become 20 is the same as for ten thousand to become twenty thousand), acting one day early will make a significant difference.
India acted early in the course of the pandemic, banning all group gatherings at a stage when there were only 536 cases in the country. In contrast, by the time Italy locked down, that country already had 59,138 cases. Considering Italy’s population is only one-twentieth of India, the consequence of this equation is self-explanatory. A SEIR (susceptible-exposed-infectious-removed) model study by Niti Ayog, India concluded that 14,00,000 - 29,00,000 cases and 37,000-78,000 deaths were prevented by the lockdown.
A study from Columbia university has shown that 36,000 deaths (55%) could have been saved in the US if social distancing measures were implemented one week earlier. After studying the China epidemic on a SEIR model, Shengjie Lai et al projected an 18-fold increase in the number of cases if the lockdown measures were delayed by 3 weeks, and a 3-fold increase if even a week’s delay had occurred. They also projected that 66% fewer cases would have occurred in China if these measures were taken one week early.
The story of the king and the chessboard is pertinent in this context:
Once upon a time, a stranger presented a chessboard to a king.
When the king asked what he wanted in return, the man asked for “a few grains of rice”.
For the first square on the chessboard, the man wanted just one grain of rice, followed by double this number for each square. That is 1, 2, 4, 8, 16 etc.
The king who was weak at math, agreed. The first few squares went smoothly as the king expected, requiring just a few grains of rice. As the process went beyond the 16th square, the king realised something was not right about his decision.
Square no.16 took 32,768 grains, while the 24th square consumed 8.4 million. Filling the 54th square took more than the world‘s annual production of rice, and for the 64th square, a 19-digit number was needed. To fill the entire chess board, it required 1000 years of the world’s annual production of rice, that was 1844674407370,95,51,615 grains of rice.
Moral of the story:
The power of exponential growth has most people fooled by small numbers in the beginning. Thoughtlessness in calculating geometric progression and taking illadvised decisions is often referred to as “second half of the chessboard”.
In the context of Covid-19, this story delivers two important messages that many of the world’s leaders failed to realise:
1. If you want to intervene, do it early, stop the game in the first row—when the numbers are still small. If we wait for a few more squares to be filled, it will go beyond our control. Italy, US and UK made this mistake of intervening late.
2. The R-0 of a virus is the number of people that one person with the virus can infect. If one person infects an average of two people in a community, the R-0 will be 2. For the chess board and rice example above, an R-0 of 2 is used. In the Covid-19 context, it can be taken as the doubling time for cases, which is currently about 15 days for India.
However, R-0 also depends on the nature and behaviour of the population. In crowded settings where people do not follow social distancing, one person could pass on the infection to more people, and the R-0 will be accordingly higher. This
means that instead of 1, 2, 4, 8, 16, when R-0 = 2, it could be something like 1, 5, 25, 125, 625, 1325 assuming R-0 = 5. The chessboard fills up much faster in such cases.
This is the reason why early enforcing of social distancing pays rich dividends in a pandemic.
3. Prior experience helps. The people of the state of Kerala are no strangers to the concept of virus or personto-person transmission, after having fought off a Nipah virus outbreak in the recent past. The Kerala Government therefore did not have to spend much time educating the public on the basics of epidemiology. It was essentially like starting a 100 m race from the 20-metre mark. Socially responsible media and a well-educated public also helped Kerala’s cause.
Likewise, Taiwan had suffered the deadly SARS outbreak of 2003, and knew exactly what to do as soon as news broke about the Wuhan cluster of pneumonia cases.
4. Scholars in leadership positions. While discussing a complex medical topic such as a pandemic, leaders with scientific background not only can make better decisions, but also have greater credibility. As in the case of war, public trust in the leadership is important. The level of cooperation of the general public often determines the outcome. The difference between the US President and the German Chancellor is an apt example.
Prior to her political career, Ms Angela Merkel, chancellor of Germany, was a scientist with a doctorate in quantum chemistry. She is known to consult the nation’s finest medical experts before making crucial decisions. One such expert is Prof. Christian Drosten, who is the head of virology of Charite’ hospital Berlin, one of the world’s leading authorities on the subject. The German public is aware of this, and takes Ms Merkel’s advice seriously.
In contrast, US President Mr Trump obtained a bachelor’s degree in economics before taking over his family’s real-estate business fifty years ago, and his lack of scientific temperament is glaringly evident in many of his decisions and statements in the context of the pandemic.
The vice president of Taiwan, Dr Chen Chien-jen is a Johns Hopkins-trained epidemiologist. In addition, Taiwan’s health minister Dr Chen Shih-chung and the vice-premier Dr Chen Chi-mai are both medical doctors, who quickly swung into action--weeks before the rest of the world reacted. They knew a pandemic when they saw one, and did not wait for WHO to tell them what to do. In fact, they had
officially warned WHO about the disease as early as December 31—on which the organisation notoriously failed to act. Dr Chen Shih-chung’s approval rating of 91% is higher than any other politician in Taiwan.
Brazil’s president Mr Jair Bolsonaro was an army captain with no background in science or math, also notorious for his stand against education. His statements and actions during the pandemic were far from scientific, and drew widespread criticism.
5. Law enforcement keeps the world safe. In a pandemic, the wrongful actions of just a few people could compromise the efforts of all others, putting entire nations at risk from super-spreading events. Although the vast majority of people are law-abiding, public health measures are bound to fail without enforcement.
In Sri Lanka, where citizens generally obey the law, over 60,000 arrests have already been made against violators of curfew and quarantine. Several European nations have enforced stiff penalties to law-breakers.
Comparison of Taiwan, Germany, US and Brazil. Active Covid-19 cases till May 30. https://www.worldometers.info/coronavirus/#countries
Singapore is yet another example of early success achieved by a law-abiding public, responding to a transparent leadership by Prime Minister Mr Lee Hsien Hoong, who is a graduate of Cambridge and Harvard University.
6. Group gatherings are dangerous. Although many things about the SARS-Cov-2 virus are still unknown, one of the most critical and indisputable facts is that this virus spreads fast from person to person, especially when people gather in closed spaces. As people talk and spend time together, aerosols (invisible droplets like mist) are generated, which are inhaled by others. Before the onset of symptoms, infected individuals carry large numbers of viruses in the throat, these are dispatched as droplets when they talk.
The ability of this virus to start spreading before the onset of symptoms makes it a never-ending chase. That is, by the time the infected person develops symptoms, gets diagnosed and is isolated, someone else is already spreading the virus and so on. Numerous group events, small and big—are documented in scientific literature with the super-spreading theme.
At the outset, by allowing small public gatherings of up to 50, Sweden surprised the world by taking a more relaxed approach to the pandemic in contrast to its neighbour Norway. However, this strategy cost Sweden dearly, when they later discovered that their death rates were six times greater than Norway. Several nations have witnessed a new surge in cases after allowing group gatherings, including South Korea and Malaysia.
Allowing group gatherings is a dangerous measure at this stage of the pandemic— the consequences of which cannot be reversed.
No one knows the ending of the story yet, but experience with this virus has consistently been that it could flare up anytime we let our guard down. While letting the economy breathe after lockdown, there must be no compromise on social distancing—at least till a medical breakthrough happens, or the virus goes away on its own.