Scenarios regarding the future of the COVID-19 epidemic outbreak in China and globally vary wildly (David Cyranoski, “When will the coronavirus outbreak peak?“, Nature, 18 February 2020). The estimates go from the outbreak peaking at the end of February 2020 to months away with millions infected (Ibid.).
The WHO Director-General stressed the necessity to remain careful as all scenarios remain possible, despite current decline in new cases in China (Remarks 17 February 2020). We have similarly differing assessments for the rest of the world.
Globally, for a while the WHO believed that we were facing a situation where efforts succeeded in keeping the epidemic under control (WHO Director-General, Munich Security Conference). As a result, it stressed these efforts must not be stopped (Ibid.).
A couple of weeks later, It is increasingly harder to believe the epidemic can be kept in check. The suggested actions remain to continue trying to contain the epidemic, even strengthening efforts.
We thus face a major risk. Actors could think that the apparently good results achieved mean that we can safely stop the various infection prevention and control (IPC) practices.
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This challenge highlights the importance of anticipation and timing in handling an epidemic outbreak. If IPC practices are eased too early, then infections could rebound and the epidemics spread. If they are eased too late, then other unfavourable impacts could spread. This is all the more difficult that uncertainty regarding the virus and its epidemiology subsist.
We saw that each actor has to take decisions regarding the COVID-19 epidemic outbreak – or any outbreak linked to a novel virus – under conditions of high uncertainty and considering complex interactions (see The Coronavirus COVID-19 Epidemic Outbreak is Not Only about a New Virus). Thus, the key is to be able to anticipate at best the various possible dynamics of the situation. This must be done with the correct model, as explained previously. And this must be done with a particular attention paid to timing.
The timing of actions is always important, but it is especially so in the case of an epidemic outbreak. Indeed, timing, for some types of actions, will have direct consequences on the spread of the epidemics, with possible cascading effects. In the meantime, timing will also have more indirect consequences on international norms, international influence and power.
The importance of timing is the focus of this article.
We shall look at the three possible cases in terms of timing of actions: too early, too late, and timely. We shall contrast the challenges linked to the start of a new outbreak and those related to a lasting or ending outbreak. In each case, using examples, we shall highlight possible consequences on the epidemic itself, on the whole spectrum of activity for entire countries and on international influence. We shall use examples related to control of mobility and to the increasingly likely global disruption to the supply of drugs and medicines.
When a new outbreak starts
When a new outbreak starts, if actions and measures are taken too early, for example, in terms of mobility’s restriction, then consequences on the economy, notably, may be disastrous (Christensen and Painter, “The Politics of SARS“, Policy and Society, 2004). Furthermore, supply chains may become even more disrupted than in case of timely actions, with potentially very severe impacts. This may even trigger scarcity in areas, which are vital and strategic.
This explains, most probably, why, by 18 February 2020, the WHO has issued no restriction on travel and trade for the COVID-19 outbreak.
Furthermore, the WHO was also criticised during the 2002-2003 SARS epidemic for having taken these very restrictions. Those were considered as having contributed to the panic (Bulletin of the World Health Organization 2003, 81 (8): 626; Christensen and Martin Ibid.). Yet, according to Christensen and Martin, the WHO finally “emerged with heightened prestige and legitimacy” (Ibid. p. 39). Nonetheless, the criticisms most probably heightened the reluctance of the WHO Committee to issue again a ban on travel and trade.
Yet, regarding the SARS outbreak, had the WHO not delivered its early warnings, the outbreak could have been worse.
When the outbreak lasts and could end
As the outbreak lasts, timing remains as difficult to handle as when the epidemic starts. We are here however, considering reverse actions. At the start of an epidemic one must set up and increase, at the right time, IPC measures. As the epidemics ends, the actions must be taken in the opposite direction, relaxing IPC measures. However, if decisions are taken too early, for example regarding the relaxation of mobility’s restrictions, then this could lead to a renewed spread of the epidemic, with even worse impacts in other areas. Timing of actions thus also impacts the length of the epidemic outbreak.
The odysseus of the Westerdam cruise ship is a perfect example for a too early relaxation of IPC measures (e.g. Chhorn Chansy, “More passengers to leave cruise ship in Cambodia after coronavirus tests“, Reuters, 18 February 2020).
For days, the ship remained at sea as ports refused to let it dock for fear of the COVID-19 infection. Meanwhile, the ship officers denied any infection. Finally, Cambodia accepted the cruise ship and let the passengers disembark. All tested negative. However, one passenger tested positive after arriving in Malaysia. As a result, now, new contact cases have appeared, and they all need to be tested (Ibid.). At worst, all passengers and staff of the cruise could be infected, although such a catastrophic scenario is not very likely.
What we see here, is a decision to relax control that is taken too early. It thus heightens the danger to see the epidemic spreading globally. The difficulty to use the current tests most probably played a part here (James Gallagher, “Are coronavirus tests flawed?“, BBC News, 13 February 2020). Furthermore, there is a rising uncertainty regarding the validity these tests (Ibid.). As a result, finding the right timing for some mobility related decisions becomes more difficult.
Dr. Mike Ryan, head of WHO’s emergencies program, tried to diffuse the problem regarding cruise ships. He remarked that:
“So if we are going to disrupt every cruise ship in the world on the off-chance that there may be some potential contact with some potential pathogen, then where do we stop? We shut down the buses around the world?” (quoted in Stephanie Nebehay, “Every scenario on the table’ in China virus outbreak: WHO’s Tedros“, Reuters, 17 February 2020).
The need to see the economic activity continuing can explain Dr Ryan’s comment. However, his statement may also have adverse impacts. It may favour a relaxation of IPC measures, when such action could be too early, as with the Westerdam cruise ship.
Furthermore, again, we note the contradictory signals sent by officials. Here, the WHO asks both to remain extra cautious and not to be in the case of cruises.
When a new outbreak starts
Not taking adequate measures early enough, even though these may appear as drastic, may also contribute to spread the epidemic. As a result, the costs across domains could be even higher.
The SARS epidemic and China
For example, China was criticised for the SARS epidemic for not having been able to handle properly and in a timely fashion the outbreak, while hiding its scale (Kelly-Leigh Cooper, “China coronavirus: The lessons learned from the Sars outbreak“, BBC News, 24 January 2020).
The costs were estimated for that outbreak to “the deaths of 774 people, spread of the disease to 37 countries and an economic loss of over US$40 billion over a period of 6 months” (John Nkengasong, “China’s response to a novel coronavirus stands in stark contrast to the 2002 SARS outbreak“, Nature, 27 January 2020, quoting Smith, R. D. Soc. Sci. Med.63, 3113–3123 (2006) and Lee, J.-W. & McKibbin, W. J. in Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary, eds. Knobler, S. et al., National Academies Press, 2004).
The Servomex Company meeting in Singapore
The string of infections stemming from the Servomex company meeting held in Singapore on 20 January 2020 is a case in point.
At this stage, the possibility and severity of seeing an epidemic was still very uncertain. On 20 January 2020, only 268 new cases had been reported (John Hopkins CSSE: Tracking the COVID-19 (ex 2019-nCoV) spread in real-time). Furthermore, all eyes were focused on China. Meanwhile, no one wanted to risk endangering the current way of life model and economic activity. Hope that it was not truly an epidemic could still prevail. As a result, no measure truly considering the possibly global character of the epidemic were taken anywhere.
Yet, the WHO had issued it first warning on the new Coronavirus and its possible spread to other countries – at the time Thailand, on 13 January 2020. It was however not assorted of any guidance regarding meetings or travel.
And here is what happened, or part of it:
- 20 January: Over 3 days, the British firm Servomex, a global gas analysis company, held a conference at the Grand Hyatt Singapore (Tan Tam Mei and Tiffany Fumiko Tay, “Coronavirus: Gas analysis conference at Grand Hyatt Singapore linked to infections“, The Strait Times, 7 February 2020). 109 employees attended the conference. Some of them arrived as early as 16 January. One of the overseas attendees had come from Wuhan.
- The 94 international attendees left Singapore and, for most, went back home, all over the world.
- 21 January: A 27-year-old Singaporean man (case 30) started developing symptoms, visited his doctor and a couple of days later a hospital (Tang See Kit, “What we know about the 3 local transmission clusters of coronavirus“, 9 Feb 2020 CNA).
- 24 January:
- “A middle-aged man from Hove, East Sussex”, after having attended the conference, went “to the French ski resort of Les Contamines-Montjoie near Mont Blanc, where he stayed with his family” until 28 January. The group was also in close contact with others in another apartment (Haroon Siddique, “‘Super-spreader’ brought coronavirus from Singapore to Sussex via France“, The Guardian, 10 Feb 2020).
- In Singapore, a 38 year-old woman from Singapore (case 36) reported symptoms, visited her doctor, then went to hospital on 4 February (Tang See Kit, Ibid.).
- 26 January: A 38 years old Korean man started to feel unwell. He visited 3 hospitals until 5 February (Chang May Choon, South Korea reports 3 new cases, including two who attended conference in Singapore, The Strait Times, 5 Feb 2020).
- 28 January: the Sussex businessman flew back home from Geneva to Gatwick with Easyjet (Siddique, Ibid.).
- 29 January:
- A British family living in Mallorca, who had been part to the holidays’ group in Contamines, flew back home (Siddique, Ibid.).
- A 41-year-old Selangor man (Malaysia) “sought treatment at a private hospital for cough and fever” (Loh Foon Fong, “Malaysian man who travelled to Singapore for work among infected“, 5 February 2020).
- A 51 year-old Singaporean man (case 39) reported symptoms. “He visited two GP clinics on Feb 3 and 5, respectively, before being admitted to NCID on Feb 6 (Tang See Kit, Ibid.).
- 30 January: The British man living in Mallorca started feeling unwell. He “show[ed] light symptoms” (Alexandra Topping and Nadeem Badshah, “New UK and Mallorcan cases linked to French ski resort cluster“, 10 February 2020).
- 1 February:
- The sister of the man from Selangor started feeling unwell (Joseph Kaos, “Two new coronavirus cases identified, bringing number to 14“, 6 Feb 2020).
- Meanwhile, the Sussex businessman “on the evening … visited a local pub, The Grenadier, in Hove” (Siddique, Ibid.).
- 2 February (probably): the man from Selangor tested positive (Loh Foon Fong, Ibid.).
- 4 February: A 36 years old Korean man, having attended the conference, self-quarantined at home, when he heard about the infected Malaysian. Indeed, he had had dinner in Singapore with him (Choon, Ibid.).
- 5 February:
- The sister of the Malaysian man tested positive (Joseph Kaos, Ibid.).
- On that same day, the two Korean men tested positive (Choon, Ibid). This sparked an investigation by the World Health Organisation (Tan Tam Mei and Tiffany Fumiko Tay, Ibid.). This enquiry possibly led to the identification of further cases below.
- The 27-year-old Singaporean man (case 30) also tested positive (Chang May Choon, South Korea reports 3 new cases, including two who attended conference in Singapore, The Strait Times, 5 Feb 2020).
- 5 or 6 February: The Sussex business man tested positive in Brighton. He was transferred to special facilities in London (Siddique, Ibid.; Sarah Boseley, Denis Campbell and Simon Murphy, “First British national to contract coronavirus had been in Singapore“, 6 February 2020).
- 7 February:
- The 38 year-old woman from Singapore (case 36) tested positive (Tang See Kit, Ibid.).
- Singapore increased its threat level for the epidemic (Siddique, Ibid.).
- 8 February:
- Five British nationals tested positive in the French Contamines-Montjoie. They had stayed with the Sussex businessman (The Guardian Coronavirus outbreak live, 10 Feb 2020, 16:34).
- The 51 year-old Singaporean man (case 39) tested positive (Tang See Kit, Ibid.)..
- 9 February:
- Another British man was tested positive in the UK. He had returned from France and belonged to the same “Contamines-Montjoie group” (Topping and Badshah, Ibid.).
- The father of the family in Mallorca also tested positive (“Coronavirus outbreak: Spanish officials say British man is country’s second case“, Global News, 9 Feb 2020). The rest of the family tested negative however (Topping and Badshah, Ibid.)
- The mother-in-law of the Malaysian man tested positive in Kuala Lumpur ( Esther Landau, “Malaysian woman tests positive for coronavirus; infections tally at 17“, The Straits Times, 9 Feb 2020).
- All contact cases are traced.
- 10 February: The UK Secretary of State declared “that the incidence or transmission of novel Coronavirus constitutes a serious and imminent threat to public health” (ibid.).
- 12 February: The business man from Sussex, Steve Walsh is “discharged from hospital and is no longer contagious” (Alexandra Topping and Henry McDonald, The Guardian, 12 February 2020).
- 16 February: A British citizen in the contact cases of Contamines-Montjoie tested positive in France (L’Express avec l’AFP “Coronavirus : un 12e cas détecté en France“, 16 February 2020).
This timeline shows how easily it is for an infection to spread completely unnoticed because actions are taken too late to stop it. Fortunately, in the case of the COVD-19, the case-to-fataliy rate is relatively low. Yet, the way it spreads remind us of worst case scenarios as depicted by Hollywood movies such as Contagion.
The spread of the contagion through this string of infection and clusters is now, hopefully, stopped, and no death will result. Yet, the risks taken were actually huge in epidemiological terms.
The cost involved in looking for multiplying cases must also be considered, as well as costs to reputation for example.
Furthermore, delayed actions also contribute to raise the level of anxiety and fear, possibly leading to even more drastic reactions by other types of actors.
For example, the Mobile World Congress (MWC) – which was to be held in Barcelona – was finally cancelled (e.g. Tom Warren, “The world’s biggest phone show has been canceled due to coronavirus concerns“, The Verge, 12 February 2020). Even though we would need detailed interviews to sort out factors and motivations in decisions, we noted that Sony and Amazon’s decision to withdraw from the event took place on 10 February, thus following the happenstance of the UK/France cluster of infection detailed above. The companies only stressed “concerns about the spread of the virus”. Ericsson, LG and Nvidia had also pulled out of the show (The Guardian Coronavirus outbreak live, 10 Feb 2020, 15:33).
Up until 18 February, the list of private actors taking similar measures be it for fairs, conferences, sporting events, tourism or manufacturing is everyday longer (e.g. Reuters daily “Latest on coronavirus spreading in China and beyond“; Reuters, “Coronavirus forces delay of trade fairs and conferences“, 18 February 2020).
Thus, late decisions regarding travel and screening actually appear to also have a large global and multidimensional impact. Considering the two coronavirus epidemics (the SARS and the COVID-19), it would be interesting, once the epidemics is over to make a thorough comparison of the two types of behaviour and of their cost.
Dangers to the supply chain of drugs and medicines and possible shortages
Late decisions may also become critical in terms of supply chain disruption. Here, however, the actions are not related to mobility and to the attempt at controlling the contagion. Actions are related to the necessity to live under conditions of epidemic outbreak.
For instance, on 14 February 2020, some European Health ministers, notably France warned of possible drug supply disruption, even though the EU commissioner took a reassuring stance (Toni Waterman, “EU health ministers warn COVID-19 could lead to drug shortage“, 14 February 2020). By 17 February, the EU Heads of Medicine Agencies (HMA) had issued no warning or report on the matter (see HMA, recently published up to 17 February 2020). The new stress impacts an already tense situation in terms of drug shortage as pointed out by the Finnish health minister (Ibid., Angela Acosta et al., “Medicine Shortages: Gaps Between Countries and Global Perspectives“, Front. Pharmacol., 19 July 2019).
In India, a “high-level committee constituted by the Department of Pharmaceuticals (DoP)” met to examine the situation regarding the export of drugs, in the context of the COVID-19 epidemic (Teena Thacker, “Panel mulls drug export curbs to avoid shortage“, The Economic Times, 10 February 2020).
Indeed, India acts as manufacturer of antibiotics with bulk drugs and active pharmaceutical ingredients (APIs) imported from China. However, it also needs drugs for its own usage, while needing to make sure prices for these drugs do not skyrocket. Hence it may decide upon restricting exports. In that case, the risk to supply in other countries would increase. India must take a decision that protects first its citizens.
On 17 February 2020, this decision, right now for “12 medicines — mainly antibiotics, vitamins and hormones” appears as increasingly likely as the expert committee will hand in its report to the government on 18 February 2020 (Sushmi Dey, “Coronavirus outbreak: Government mulls export ban on 12 essential drugs“, The Times of India, 17 February 2020).
If India were too late, then it would have to face a possibly major crisis of drug shortage and thus a health crisis. Meanwhile, other actors need to factor in not only India’s possible decision regarding exports’ restrictions, but also its timing as it will impact reserves and the supply chain. Furthermore, if we imagine as is likely that finally India decide to restrict export, then others’ actors decisions which could have been timely otherwise may suddenly become too late. In turn a new sanitary crisis may be triggered elsewhere.
In the U.S., advocates and groups seeking to rebuild a national capability in terms of drug production point out the risk in terms of national security (Michele Cohen Marill, “The Coronavirus Is a Threat to the Global Drug Supply“, 28 January 2020). Here we also see cascading impacts at work: ancient decisions regarding production of drugs led to outshoring of key drugs’ components. From the point of view of ensuring indeed drug supply in case of a lasting outbreak in countries producing these key component – in our case China – decisions to face and mitigate the possibility of such possible shortages should have been taken before the epidemic outbreak. The problem for the U.S. as for other countries, is also heightened by India’s role as manufacturer and the possible exports’ restrictions.
So any decision taken once the outbreak is at work is probably too late, as capabilities to manufacture drugs and their components cannot be created instantaneously.
Of course, concerned actors need to carry out very detailed analyses per drug and component, factoring in all impacting variables, as explained previously.
Similar analyses will need to be done for any sector and any product.
In the meantime, the sudden awareness of the risks taken may well contribute to fundamentally change the international system with a redefinition of national policies in terms of drug production. The very norms of the international system here will likely be impacted. Indeed, the current trend towards a nationalisation of globalisation we observed in 2016-2017 is likely to be strengthened (see Helene Lavoix, Beyond the End of Globalisation – From the Brexit to U.S. President Trump, 17 February 2017).
When the outbreak lasts and could end
Here we would be in the case of actions that were taken too long after the epidemics actually ended. It is, however, not truly possible to identify such actions as the outbreak has not ended.
Nonetheless, for the sake of the exercise, we shall mentally, briefly, look at such a possibility in the case of the possible shortage of drugs. We shall also do it because, as the epidemics lasts and as other interests are imperilled, there is an increasing likelihood to see some actors using the argument according to which actions are not needed anymore to pressure others to see a relaxation of IPC.
For example, EU Chamber of Commerce President Joerg Wuttke warned that “The world’s pharmacies may face a shortage of antibiotics and other drugs if supply problems from China’s coronavirus outbreak cannot soon be resolved” (Gabriel Crossley, “China virus outbreak threatens global drug supplies: European business group“, 18 February 2020). This is a warning that is consistent with what we highlighted previously.
However, he also adds that China makes things worse”with a mandatory quarantine of arrivals from abroad as it battles the virus” (Ibid.). Mr Wuttke may be partly right, but the quarantine China imposes may also have as aim to avoid reinfection, which is always possible.
Should China relax the quarantine for arrivals from abroad, we may imagine that contagious foreigners could enter the country and create a new cluster of infection. In turn, this would just deepen all supply problems and not solve them. We would here be in a case of a relaxation of IPC measures taken too early.
However, Mr Wuttke’s point may be understood as the opposite, that some of China’s measures are lasting too long. For him, relaxation measures will be too late.
As an epidemic lasts, stress increases and multiple impacts, notably unfavourable, develop. To the least, what was the norm and the system has to change, when human beings in general fear change. Meanwhile, compared with the start of a new outbreak, knowledge and understanding has improved, but not enough to allow for the disappearance of epidemiological uncertainty. As a result, it also becomes increasingly difficult to assess the proper timing for all actions.
Timely is very difficult but benefits are numerous
As the cases explained above made clear, acting in a timely manner is very hard in the context of a new epidemic outbreak.
Compared with what we saw for the SARS epidemic, so far, the Chinese political authorities’ handling of the COVD-19 outbreak is considered as having progressed as lessons were learned (Cooper, Ibid., Nkengasong Ibid.). The WHO highlighted and welcomed the commitment and enormous efforts of China (Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV), 30 January 2020).
On 15 April 2020, the WHO Director-General reasserted this assessment at the Munich Security Conference, interestingly stressing the time component:
We are encouraged that the steps China has taken to contain the outbreak at its source appear to have bought the world time, even though those steps have come at greater cost to China itself. But it’s slowing the spread to the rest of the world.
Yet, even in that case, uncertainty remains as to the global spread of the epidemic. The European CDC underlines both the Chinese efforts and the remaining uncertainty:
“The scale of these measures [those taken by China] is unprecedented and the economic costs of such measures to the Chinese economy are considerable. Although the effectiveness and collateral effects of these measures are difficult to predict, they are expected to limit the immediate likelihood of further spread of the virus via travellers returning from Hubei province and China in general…”ECDC RAPID RISK ASSESSMENT Outbreak of acute respiratory syndrome associated with a novel coronavirus, China – third update. 31January 2020 – p.4.
Using these comments and assessments, we see that taking as timely as possible measures is commended internationally, even though incertitude may remain.
First and obviously, timely actions protect the population, which is or should be the first priority for any political authority that wishes to remain legitimate (Moore, Injustice, 1978).
Furthermore, the article assessing China’s efforts in Nature goes on highlighting a need for preparedness for Africa (Nkengasong, Ibid.). China is thus used as example for Africa (Ibid.). This may be an early signal that China will be able to extend its influence as a consequence of its handling of the new Coronavirus epidemic.
The feat of successfully building a 1000 bed modern real hospital in 7 days will also, most probably, be a component of future Chinese influence. Indeed, it very practically demonstrates capabilities and thus power. We shall note that all steps of the construction then opening of the hospital were monitored and publicised worldwide in international media and through social networks (e.g. Amy Qin, “China Pledged to Build a New Hospital in 10 Days. It’s Close,” The New York Times, 3 February 2020). This is not to say that it was all a plot by the Chinese authorities. However, the Chinese were smart enough to think long term. They widely publicised their immense efforts to control and overcome the COVID-19 epidemic outbreak.
As seen in this article and previous ones, the highly uncertain conditions surrounding an epidemic outbreak, the difficult anticipation, the need to assess properly the timing of actions, all contribute to the diffusion of confusing messages.
However, as we are forced to try to understand we reasons for confusion, we can also progress towards a better model to anticipate, and plan ahead in the context of an epidemic outbreak. Meanwhile, the way we can usefully monitor the epidemic also improves.
We still have to make sure that our model is fit for the current epidemics and for the coming ones. Thus, we have to make sure that no cognitive biases block understanding and that novel factors are also included. This is what we shall see with the next articles.
Further detailed references and bibliography
Tom Christensen & Martin Painter (2004) The Politics of SARS – Rational Responses or Ambiguity, Symbols and Chaos?, Policy and Society, 23:2, 18-48, DOI: 10.1016/ S1449-4035(04)70031-4.
Moore, B., Injustice: Social bases of Obedience and Revolt, (London: Macmillan, 1978).
Credit Featured Image: “This is a picture of CDC’s laboratory test kit for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). CDC is shipping the test kits to laboratories CDC has designated as qualified, including U.S. state and local public health laboratories, Department of Defense (DOD) laboratories and select international laboratories. The test kits are bolstering global laboratory capacity for detecting SARS-CoV-2.” [Public Domain]