Difficult
though it may be for us to acknowledge, the Covid-19 Pandemic has been, for all
the deaths, illness, social dislocations and economic damage, a relatively
“mild” pandemic by historical pandemic standards. With decades of warning and
preparation, the arrival of Covid-19 was a surprise only in as much as the
specific virus was not ‘expected’.
There
are lessons to learn from governments, enterprises, communities and people’s
responses to the Covid-19 Pandemic. We can look at those and extrapolate
potential responses to a “Real Pandemic” of historical proportions. The Black
Death (and subsequent pandemics of plague), and the “Spanish Flu” of 1918 are
informative. While a repeat of the 1347 to 1350 Bubonic Plague is highly
unlikely, a new flu or another pathogen with an impact similar to or greater than
the 1918 Spanish Flu is quite possible.
This one was "easy"
The
Covid-19 Pandemic is not over, and probably won't be for months to come,
possibly a year or even two. The initial impact was one of illness, death,
social distancing and dislocation brought on by seemingly interminable
lockdowns. The daily litany of reports of illness and death out of Northern
Italy and then New York, the seeming ineffectiveness of lockdowns, and the
constant drumbeat of doom from all media sources, if not from governments,
which varied from near panic to attempts at convincing their people that there
this would pass quickly and was "just like the flu". Early in the
pandemic, many governments told people that masks were not necessary for the
general population, and were only required by medical professionals or those in
close contact with Covid-19 patients. That advice changed later, but the damage
to these governments' credibility around the world was substantial.
Fast action by other governments in many countries ensured that
the immediate economic impact was limited, and recovery fairly quick once
general lockdowns were lifted. There remain lingering economic problems, not
least continuing disruptions to supply chains around the world. Employment is
rebounding, and the United States is almost back to pre-Covid-19 employment
levels according to the (flawed) percent unemployed rate.
Perhaps
because of the (relatively) early warning and surveillance, the total number of
cases and deaths was actually relatively light, when compared with previous
pandemics. This is not to downplay the amount of suffering at the individual,
community and national levels. The official number of deaths, at almost five
million globally, is most certainly understated by possibly a half or more, and
a final tally will not be available for years. Yet, the number of deaths
compared with previous pandemics has been low. With “Long-Covid”, the health
impacts on those who contracted Covid-19 will haunt societies for decades to
come.
What have we learned?
Now that
Covid-19, although still a considerable danger, is being brought under some
measure of control, we can consider some of the lessons that we can learn. I am
confident saying that Covid-19 has brought under some measure of control as vaccines
and specific treatment protocols have evolved to greatly reduce the risk of
mortality once an individual does contract Covid-19. And these vaccines and
treatments were developed and testing in record time, founded on decades of
research and an influx of substantial investment.
Some of our
specific lessons that we should take away in anticipation of a future pandemic
include:
Science and Medical Science. First the good
news. The resources that were mobilised to develop and produce multiple
effective vaccines has been stunning. The ability of the medical profession to
quickly learn what therapeutic interventions work and which don’t was equally
remarkable.
Government Transparency is still the cornerstone. Governments generally failed in
providing honest and transparent information to their people. In some cases is
was done for the right reasons, but frequently giving the appearance of amounting
to secret agendas. This was exacerbated by government ministers in various
countries flouting the regulations imposed on the rest of society. Furthermore,
when a national leader is more worried about his image than the people, danger
lurks. Refusing to allow passengers off an infected cruise ship to “keep the
number down” reinforces distrust. Being quoted as advocating “herd immunity” as
a national strategy while also holding daily “flatten the curve” briefings also
erodes confidence.
"Flattening the Curve" worked. As discovered
during the “Spanish Flu”, the biggest danger was that healthcare systems would
become overloaded and care would need to be rationed. In much of the developed
world the healthcare systems survived, although in cases they were strained
almost to breaking point. Yet other countries provided lessons on what happens
when the system is overloaded. In India in the second quarter of 2021, the
healthcare system collapsed. The official death toll was 425,000 but the real
death toll is estimated to be between eight and ten times that number. In
Ecuador in 2020, the queues of cars and trucks carrying coffins into the
central cemetery in Guayaquil suggested a death toll many times the official
figures.
Medical and Critical workers suffered. The unrelenting pace of the pandemic in the first and second
waves exceeded the capacity of many workers to cope. Unfortunately we are
discovering that the denigration of medical works by conspiracy theorists
combined with months of unrelenting overwork is driving many to leave the
profession, that medical workers; nurses, doctors, and specialist support
staff. We also discovered that “critical workers” are not the accountants and
lawyers, but the rubbish collectors and supermarket checkout clerks.
Conspiracy theorists are all around us. Some will never accept the science, and will
seek conspiracies and “Youtube Research” as the method to find some hidden
secret; some undiscovered already existing treatment (suppressed by Big Pharma
of course), a plot to impose tyranny or even outright denial. In New York City
during the first wave in 2020, Covid-19 deniers were videoing the parts of
emergency rooms and hospitals they were able to access, in order to “prove”
that it was all a hoax. Unfortunately, the failure of adequate transparency
contributed to this phenomenon.
Lockdowns have a limited acceptable span. While people are willing to lockdown at the height of a
pandemic, there is a limit to people’s patience. The problem is that stopping
the spread of a pathogen that is airborne and highly contagious is not
something that just happens. Lockdowns are designed to deprive the virus of
hosts, by limiting the potential number of people who can be infected. The
problem comes when lockdowns are broken, and when “it won’t happen to me”
becomes the prevailing sentiment. In the US, France, Greece and Australia,
people held rallies and marched against lockdowns, creating their very own super-spreader
events in the process.
Business showed surprising resilience. Certainly, the sudden shutdown of commerce came as a huge
shock, but a combination of government fiscal stimulus and “work from home”
directives helped cushion the blow. In countries with overt salary replacement
(or partial replacement) by the government, redundancies and lost jobs were
more limited than expected. A contrast is the United States which saw over 20
million people lose their jobs within a matter of a month and a half. The “V”
shaped recovery has yet to fully replace those jobs, and labour market
participation rates have stabilised at a lower level than pre-Covid-19.
Technology has come of age for remote working. Before the pandemic, concepts, such as
telemedicine and remote “visits” to the doctor, were interesting, but there
remained too many cultural and technical impediments. Allowing workers to work
from home (or from anywhere) were considered leading edge and fraught with
expectations of collapsing worker productivity. Both are now setting the
standards for medical care and business operations into the future.
Supply-chain impacts are "long tails". Just-In-Time was the pre-Covid-19 mantra for an effective and
profitable business. Exactly the right number of chips in the right place at
the right time would hold down costs, push products out faster, and provide
flexibility. This model works for Christmas ornaments as it does for automotive
chips, as it does for delivering sweatshop-produced garments to stores across
the developed world. In early 2020, global shipping stopped. Close the chip
factories and the backlog of chips grows. Stop the ships and the backlogs grow,
and once shipping is restarted, the backlogs become apparent. There may be a shift
away from JIT to JIT Plus Buffer.
A
pandemic is a politically exploitable
situation. Finally, too many leaders found an opportunity to use the pandemic
as a tool to amplify the “us versus them” of their local politics. This was
most notable in the US (injecting light or Clorox anyone?) where public health
measures, misunderstood by many and rejected as another government imposition,
could be exploited as further evidence that the “Deep State” wishes to control
people, and that Covid-19 is just another tool to accomplish that. In Brazil,
the President openly declared that it was nothing to worry about, even as the
death toll climbed and graves could not be dug fast enough. China blaming has
also been unhelpful.
These are
only a sample of the lessons we can take from Covid-19, and I’m fairly
confident that I have missed some of the readers’ personal learnings. But all
of these will matter, deeply, in the coming pandemic. The “Real Pandemic” that
may kill ten or more times Covid-19s toll, and could happen any day now. For
all we know, the pathogen that will become our new nightmare may already be
circulating, just waiting to catch the international flight being called at
Gate 15 right now.
What might the next pandemic (the "real"
one) be?
Before we
look at what we should be doing in anticipation of the coming Pandemic, let’s
see what other pandemics have looked like, and consider a likely candidate for
the next “Real Pandemic”.
Plenty of potential pathogens
There certainly are plenty of pathogens to choose
from, ranging from the all too familiar annual influenza to the exotic. It
would be easy to provide a list, but that would not be helpful, though it would
be scary. Ebola would probably be on most people's list, but there are other
haemorrhagic fever pathogens such as Marburg And we should not forget the
other SARS variants from the "original" SARS (serious enough) to MERS with a much higher mortality
rate, at around 30% to 40%. Here however we'll only look at three; Plague,
"Spanish Flu", and Avian Influenza. Why? Because the Plague gives us
a benchmark of the worst case (we hope) while "Spanish Flu" provides
a precursor to what I think is the most likely next major pandemic; Avian
Influenza.
This is not to downplay the very real likelihood of
Covid-22 or even Covid-23, etc. But for each of these, we can hope that the new
versions will not be so novel as to be beyond the flexibility of the current
mRNA vaccines technology to respond rapidly.
The Great Mortality
When it happened, the "Black Death", as we
know it today, was called the "Great Mortality", and with good
reason. The total mortality across Europe appears to have been between 30% and
50%, and higher in specific locations. While Bubonic Plague (caused by the
bacterium Y. pestis) is
generally accepted as the cause of the Great Mortality, there are some who
think it may have been caused by other diseases, including plague, but also
potentially including a haemorrhagic disease.(1)
Originating in Central Asia and making its way
westward, the Plague travelled at roughly the speed of sail, and overland at
the speed of an oxcart. Were it able to spread at the speed of air travel, the
mortality would have been the same, only the duration of the Plague, until it
had exhausted the available human population, would have been quicker?
Our best records for the speed of spread and
mortality of the Black Death comes from church records in England. By fate of
history and good luck (and the absence of successful invaders since 1066), church records across England have mostly survived. These paint a picture of
the plague as it marched across the country. These also provide a picture of
the total mortality being between 30% and 50%, with outliers of course. For
example, the Abbey at St Alban's was badly hit by the plague, and "there
were few left to mourn the good man: forty-six other St Alban's monks died in
the plague, nearly three-quarters of the strength of the monastery."(2)
Bubonic Plague is yesterday's plague, though it does
continue to pop up around the world even to this day. But we know how to treat
it, and it appears to have mutated over the centuries and has become a less mobile
and easier to treat illness. So, barring some very strange mutations, the next
Pandemic will probably not be a variant of Bubonic Plague.
1918 "Spanish" Flu
Influenza is probably the biggest risk, and there
are precedents to warn us. The most worrying is the 1918 "Spanish
Flu" pandemic. It is worth remembering that the current death toll from
Covid-19 is just under 5 million, with the probable actual total being closer
to double that (thought realistic final estimate will not be known for some
years). The 1918 pandemic saw a global total of 50+ million dead, based on a
global population that was about a quarter of the current global population.
In the Covid-19 Pandemic, the early call was to
"flatten the curve" to ensure that the health system could cope with
the projected load. The 1918 pandemic gives us a stark reminder of why this was
so important, and why failure to "flatten the curve” was such a scary
prospect to health planners and governments.
Camp Devens outside Boston in the US was designed to
house 35,000 soldiers awaiting transport to Europe to fight the Germans. In
early September it held 45,000 troops. The flu began to spread in the camp. “On
23 September William Henry Welch, one of the most distinguished physicians of
the day, arrived bringing with him a team of America's leading medical experts.
By that time, in the two weeks since it started, 12,604 men had fallen ill;
sixty-three died on the day Welch arrived. Some took ten days to die; other
were gone inside forty-eight hours. Hospital wards overflowed on to the porches
and into commandeered barrack huts, and the bed linen was stained everywhere
with blood and phlegm."(3)
In the Covid-19 Pandemic, most supply chains and
agricultural production (in the developed world) continued to function, with
some gaps. In 1918 the impact was far worse. In India, the monsoons had failed
in parts of the country. "With over half of the population falling sick
(and with the most severely affected people being those from twenty to forty
years old), the harvesting of what crops there were was drastically affected.
Production of feed crops declined by nearly 20 per cent compared to 1917; as a
result food prices doubled, and the malnourished rural poor spilled into the
disease-torn cities enfeebled and destitute."(4)
Avian Influenza; a potential next pandemic
Flu remains one of the biggest pathogen killers,
Covid-19 notwithstanding. And through the Covid-19 Pandemic, the widespread use
of masks seems to have resulted in a season without flu. Instead of rejoicing,
there are now worries of a harder than usual flu season to come.
But what happens if an Avian Influenza not only
leaps the species barrier (which happens a few times every year, but seems to
have accelerated over the past year). "Only 46 human cases of H5N6 bird
flu have been confirmed since the first case in 2014, but nearly a quarter of
them have been reported during the last 2.5 months. At least 22 cases, all but
one of them in China, were reported during the last year. H5N6 bird flu is known
to cause severe illness in humans of all ages and has killed more than half of
those infected, according to WHO. There are no confirmed cases of
human-to-human transmission." (https://bnonews.com/index.php/2021/09/young-woman-dies-of-h5n6-bird-flu-in-southern-china/)
Most worrying is the small number of mutations that
would be required in the Avian Influenza genome to turn it into a human
transmissible virus.
If you have a sudden desire to be afraid, read the
article "Three mutations switch H7N9 influenza to human-type receptor
specificity" (https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1006390). The idea that three mutations
can turn Avian Influenza into a high-mortality human-to-human pathogen is more
than a little scary.
Being clear, I'm no "Youtube Researcher",
and that article was written for people much smarter than me; people who
understand the genetics of influenza and mutations. It is still a worrying
article to read, even if I candidly admit that I understood little past the
abstract and introduction. It is enough to convince me that Avian Influenza, or
another influenza, may well be our next major pandemic.
Implications for the "Real Pandemic”
In
part the list of lessons from Covid-19 form a core of our implications for the
“Real Pandemic”.
Surveillance should see it earlier. There exists a strong international set of guidelines and
processes for the notification of “reportable diseases”. The monitoring of
these is a national security issue, and hopefully will receive the funding and
priority that will be required to reduce the impact of the coming pandemic.
Worryingly, national politics and concerns as
witnessed during the Covid-19 Pandemic could still result in a delayed release
of full information. Anyone who was not concerned when China locked down 56
million people simply was not paying attention.
Transparency will remain critical. Governments will need to be transparent to both calm their
populations, but so to be clear
about what they do not know. The failure to be clear about the unknowns may
have contributed to the loss of confidence in government institutions. Still, seeing
the spread of a potential pandemic causing pathogen may not result in fast
action by any government. Internal agreements or disagreements over
jurisdiction may contribute to disagreements over the severity of any release
or new pathogen.
Hesitance on the part of governments. Some governments will be hesitant to respond. The burden that
Covid-19 placed on countries and on governments will serve as a dampener to
rapid and effective quarantining and international border closers. Furthermore,
the political cost of fast and assertive response may be perceived as being too
high. “This won’t be a SARS or Covid-19” mentality will prevail until it is too
late. Yet there are the tools that worked, and will need to be implemented to
stop the spread of the new pathogen. It
is probable that in many countries, there will be active rejection of
restrictions, and large segments of the public may actively oppose government
action.
Business will respond faster than
governments. Much of the response will be
culture-driven with the science taking a back seat. The driver will be workers
who are watching, and beginning quickly to say that they feel unsafe commuting
or being back in offices. We will see more hedging sooner of transport capacity
including air cargo, and filling their JIT pipelines and inventories. On the
downside, we may also see layoffs happening sooner in the cycle, as businesses
cut staff earlier to hoard cash.
Medical and critical workers are not disposable, and cannot be easily replaced. A new
pandemic could see these workers suffering PSTD type symptoms, with the danger
that critical infrastructure may fail due to these workers cracking, or simply
not showing up. Nurses who have been overworks and maltreated may decide that
they would rather stay home and take care of their immediate loved ones,
especially if the Next Pandemic is as serious as it could be.
Conspiracies will never die. Individuals will quickly split between conspiracy-theorists
and rational people, with the rationale opting to avoid proximity, panic buy
and prepare for personal lockdowns. Meanwhile the conspiracy-theorists will buy
ammunition and will take to the internet “airwaves” to spread their message. Outside the US, the anti-vax, anti-science percentage of most
populations is relatively small, including those who were hesitant to be guinea
pigs for the new, ‘untested’ vaccine (many of whom have now been vaccinated).
There certainly are those that are ambivalent, or even wary, but for the most part
they will "listen to the science".
A higher death toll quickly will enforce lockdowns. In the Covid-19 Pandemic, lockdowns were, mostly, effective.
In the coming pandemic, lockdowns will be self-enforced, as a rising death toll
and the associated media and fear act to drive people indoors and away from
others. Lockdowns, mandated or ad-hoc, will come into force sooner and will
stay in place longer, enforced by communities themselves. Lockdown ‘breakers’
will be shunned, and denial groups will, while receiving plenty of media, find
themselves equally isolated.
What can we do to prepare
Entities
Review & Revise contingency plans.
A pandemic could hit at any time. That we have made it through this one
(almost) does not suggest that another one could not already be brewing. Build
the internal and external communications frameworks that will allow rapid
response to quickly changing conditions. Test contingency plans to ensure they
will work, and to learn from what didn’t. Most importantly, perform an in-depth
“after action” review of how the entity responded to the Covid-19 Pandemic.
Review IT systems and capacity. A CIO I
know, in developing a system, said that he wanted anyone to be able to access
the system from anywhere. He begrudgingly agreed that anyone authorised should
be able to access from any authorised location. That has served them well, as
they were able to implement distributed customer support almost immediately.
Companies should also retain a larger stock of pre-configured laptops. Another
entity had 600 laptops in the process of being commissioned and decommissioned.
This allowed them to rapidly equip a workforce that could no longer work from the
office.
Reconsider the supply chain. Look to hedge
what can be hedged, and look to increase critical inventories, and accept that
a certain level of inventory “fat” may be appropriate to ensure continued delivery,
especially if your competitors are unable to deliver. Review your supply chain
with specific attention to the resiliency of each of the entities in your
extended supply chain. Consider which elements of the supply chain can suffer
disruption without excessive impact on business operations.
Confirm community relations. Companies and
entities do not exist in a void, and need to be able to demonstrate their “good
corporate citizenship”. This is true especially in times of distress. Consider
plans on how not only employees and their families will be supported, but also
how the entity will ensure its communities remain sane and sound.
Plan for After. After a recession there is growth,
and after the pandemic there will be growth. Consider (and plan for) how the
company will position itself to take advantage of the post-pandemic period.
Will there be market opportunities? Will competitors be weakened and their
market share at risk (or opportunity). Will suppliers be positioned to meet the
entities needs in a post pandemic growth phase, and if so, what needs to be put
in place now to ensure that the entity is at the front of the queue for
capacity?
Personally
Each of us
has a responsibility to ourselves, our families, our communities, and to our
businesses and civil society (and the law). The following are a few
suggestions. I am not a “prepper” and to not make pretences to be one. But
there are a few precautions I take. Most of these are the precautions you
should have in place anyway if you live in a hurricane zone or in a place prone
to earthquakes.
Be/stay alert. Here I recommend that people
subscribe (free) to the International Society of Infection Diseases “Promedmail”
service. This is a great source of unending worry and potential panic, if only
because it will send you an email of each case of a reportable disease. In
January 2020 Promed Mail started to send out emails referencing a new pathogen
in China.
Keep stocks of PPE. Unlike for a hurricane or
earthquake, PPE is pandemic risk specific. Again, at the end of January 2020,
after seeing the Promed emails and as Covid-19 (unnamed at that time) was just
beginning to make news, I ventured to the local DIY shop and bought masks and
protective suits. I then came home and put them away, chiding myself for being
a worrier. I still have the protective suits, because thankfully I’ve not
needed to use them.
Keep stocks of food. Again, I decided very early
that we would need to be able to close the door for three weeks. That’s a long
time when you consider what actually is needed. As a learning, when buying a
three week supply of food and beverages, remember snacks. Being locked inside
is much better with snacks. But also remember easy to prepare but easy to store
for a long time foods. Remember water. Long-life milk is good to keep in the
pantry. Buy your toilet paper long before you will be competing with everyone
else for the last rolls on the shelf.
Don’t buy ammunition. If you need it, it will be too
late, and it will not help you.
Footnotes:
(1)
The Great Mortality; An Intimate History of the Black Death, the most
devastating plague of all time. John Kelly, 2005.
(2)
The Scourging Angel; The Black Death in the British Isles. Benedict Gummer,
2009.
(3)
Catching Cold. Pete Davies, 1999
(4)
Ibid.
