The Red (Team) Analysis Weekly – 9 April 2020 – COVID-19 Cognitive Overload?

This is the 9 April 2020 issue of our weekly scan for political and geopolitical risks (open access). Again, a very large part is devoted to the COVID-19. Read the scan below, after the editorial, quite long this week.

Editorial

First, this week’s scan features the excellent article “Stretching the International Order to Its Breaking Point” by Thomas Wright, Senior fellow at the Brookings Institution in The Atlantic. The highlight for the article reads:

“The greatest error that geopolitical analysts can make may be believing that the crisis will be over in three to four months.”

It is not only geopolitical analysts that are making this error, but, apparently, an increasingly large majority of people, whatever their position and role in the system.

    As we progress here, at The Red (Team) Analysis Society, with the building of scenarios for the COVID-19, the idea of a crisis with a rapid end looks more and more improbable, not to say impossible. The COVID-19 is a pandemic, caused by a highly contagious, dangerous virus about which we know extremely little. It is highly improbable it disappears as if by magic, because it is inconvenient to human beings.

    The sketch Wright paints for the future is highly interesting and is definitely a must read.

    The second point I would like to make for this scan, considering the signals collected, is the incredible sheer mass of texts, articles, posts, etc. produced on the COVID-19. It is not only the COVID-19 cases that grow exponentially, but also publications about it. Thus, we are also faced with the dangers of a huge information overload. It is impossible to keep track of all the articles. It is impossible to even skim through them to sort out quality articles from rubbish, serious articles from fake news, scientific analysis from mere opinion. We certainly cannot rely on Google or search engines, as their algorithms rarely privileges quality and relevance. Google, for example, in its ranking, puts a high premium on page-speed and commercial stuff. But are these truly important criteria to find truly crucial articles on key uncertainties regarding the COVID-19?

    The COVID-19 information overload will accelerate the need for closure, which is already enhanced by the stress and the crisis. The need for closure is the imperious need to get answers, any answer, immediately. It rises notably with time-pressure, critical when going through duress and crisis, and with environmental noise, which includes information overload (for more on the need for closure, cognitive biases in general and strategies to mitigate them, see our online course 1 – Geopolitical Risks and Crisis Anticipation: Analytical Model – module 2). Of course, when faced with a pandemic, jumping to decisions and responses is not a very good idea. On the contrary, one needs to think peacefully and to use evidenced-based analysis, and to wait, when necessary, until proper analysis and science-based findings become available. Thus one needs to have a low need for closure.

    Now, the very means we have to obtain analysis and scientific articles, the web, because of the massive amount of texts on the COVID-19, creates an information and cognitive overload that, in turn, generates need for closure thus stops the capacity to think. Thus, to be able to know, we impair our ability to think.

    Disaster looms.

    Actors will probably fall back on classical means to obtain information: the system as it exists (which includes also the pre-COVID-19 Google, Bing and others algorithms). But, this directs us to ask a very inconvenient question.What led us all to first an outbreak of a completely unknown disease, then to an epidemic then to a pandemic, with all the unpreparedness that is everywhere increasingly documented is this very system. Hence, is that system the best to select the relevant and reliable information we need to face and overcome the pandemic?

    If not the system then what? Could part of the system be salvaged and should other parts be abandoned? Here our topic is selection of quality and relevant analysis, but should these questions be also extended to the whole system?

    The Scan

    Using horizon scanning, each week, we collect weak – and less weak – signals. These point to new, emerging, escalating or stabilising problems. As a result, they indicate how trends or dynamics evolve.

    The 9 April 2020 scan→

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    Horizon scanning, weak signals and biases

    We call signals weak, because it is still difficult to discern them among a vast array of events. However, our biases often alter our capacity to measure the strength of the signal. As a result, the perception of strength will vary according to the awareness of the actor. At worst, biases may be so strong that they completely block the very identification of the signal.

    In the field of strategic foresight and warning, risk management and future studies, it is the job of good analysts to scan the horizon. As a result, they can perceive signals. Analysts then evaluate the strength of these signals according to specific risks and dynamics. Finally, they deliver their findings to users. These users can be other analysts, officers or decision-makers.

    You can read a more detailed explanation in one of our cornerstone articles: Horizon Scanning and Monitoring for Warning: Definition and Practice.

    The sections of the scan

    Each section of the scan focuses on signals related to a specific theme:

    • world (international politics and geopolitics);
    • economy;
    • science including AI, QIS, technology and weapons, ;
    • analysis, strategy and futures;
    • the Covid-19 pandemic;
    • energy and environment.

    However, in a complex world, categories are merely a convenient way to present information, when facts and events interact across boundaries.

    The information collected (crowdsourced) does not mean endorsement.

    Featured image: Milky Way above SPECULOOS / The Search for habitable Planets – EClipsing ULtra-cOOl Stars (SPECULOOS) is searching for Earth-like planets around tiny, dim stars in front of a panorama of the Milky Way. Credit: ESO/P. Horálek.

    The COVID-19, Immunity and Isolation Exit Strategy

    One of the critical and key uncertainty about the COVID-19, among so many, is the immunity a patient may have after recovery from the COVID-19. In other words, can someone who recovered from the COVID-19 catch the disease again and infect other people again?

      As long as we have neither vaccine nor fully efficient antiviral treatment, specific acquired immunity, i.e. the immunity developed as the body fights then recovers from the disease, is one of the key variables at the center of the few solutions we have to handle the pandemic. Because, as we saw, we shall not be able to use vaccination for immunisation before at the very best winter 2022, and considering the uncertainty considering treatments against the SARS-CoV-2, specific acquired immunity becomes even more important.

      This immunity is also key to determine exit strategies to isolation and lockdown. Indeed, one of the components of the exit strategy that may be designed is to allow people who have developed an acquired immunity to return to normal life (e.g. Ran Balicer, “Coronavirus: Two Things Must Happen Before Initiating Exit Strategy“, Haaretz, 2 April 2020).

      Thus what do we know or not, so far, about this immunity? How can we handle the uncertainty? Finally, what does that imply for an exit strategy? This is what we shall see in this article.

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      Many questions and few answers, yet.

      In a nutshell and schematically, when a pathogen such as the SARS-CoV-2 enters the body, the immune system develops a range of reactions to fight against the intruder and attacker (for a very interesting clear, detailed biological and medical explanation see, for example, “Features of an Immune Response“, in Immune System Research, National Institute of Allergy and Infectious Diseases). The creation of antibodies is one of these responses. Antibodies will attack the intruder. If the immune system is victorious against the SARS-CoV-2, then the patient recovers. His or her body keeps traces of war that took place. The patient will now also have an acquired immunity (e.g. Encyclopaedia Britannica, “Immune System“).

      However, as Morgane Bomsel, virologist and immunologist underlines:

      “The question is to know if it [the acquired immunity] will be protective of nor, and how long it will last” (La question est de savoir si elle va être protectrice ou pas, et combien de temps elle va durer) .

      in Camille Gaubert, Interview with Morgane Bomsel, “Covid-19 : l’immunisation pourrait, chez certains, ne pas protéger d’une deuxième infection“, Sciences et Avenir, 1 April 2020)

      Protective acquired immunity after recovery from the COVID-19?

      First, thus, one needs to find the various components of the acquired immunity in the body. For example, antibodies need to be present in such a quantity that they are sufficient to prevent infection again (Wu, IBId., Callow, K A et al., ibid.). Such antibodies were detected in a patient with mild-to-moderate symptoms “before symptomatic recovery. These immunological changes persisted for at least 7 d following full resolution of symptoms” (Thevarajan, I., Nguyen, T.H.O., Koutsakos, M. et al., “Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19“, Nat Med; 2020).

      Then, Linlin Bao, et al., in a not yet peer-reviewed article, showed on rhesus macaques that those could not be reinfected, “after the symptoms were alleviated and the specific antibody tested positively”, at 5 days post-infection (“Reinfection could not occur in SARS-CoV-2 infected rhesus macaques“, bioRxiv, 14, March 2020.

      On 27 March 2020, the Helmholtz Centre for Infection Research (HZI) in Germany announced the start of a much larger study, on 100.000 individuals. The donors’ “blood will be regularly tested for antibodies against the Covid-19 pathogen. The study will provide a more accurate picture of immunity and pandemic development.” The center goes on highlighting that following this study, one may imagine giving a kind of immunity certificate to people who developed an immunity, which would allow them to return to normal life (Ibid.). The tests should start in April 2020 and first results should be available at the end of the same month (Veronika Hackenbroch, “Large Antibody Study to Determine Germans’ Immunity to Covid-19“, der Spiegel, 27 March 2020). Improvements in the test procedure – thus reliability of the study – should take place between end of May 2020 and end of June 2020 (Ibid,).

      Thus, it would seem, according to what we now know, that we indeed obtain a protective acquired immunity. Utmost caution, however, must still be exerted waiting for other studies’ results, such as the German study.

      Furthermore, we must also account for the possibility, that, for some individuals, a different immune response develops. In two other coronaviruses, the SARS and the MERS, for some people, the antibodies facilitated infection rather than preventing it Camille Gaubert, Interview with Morgane Bomsel, “Covid-19 : l’immunisation pourrait, chez certains, ne pas protéger d’une deuxième infection“, Sciences et Avenir, 1 April 2020). Favourable results for experiments in vitro gave opposite, negative results in vivo experiments (ibid.). If such were the case for the SARS-CoV-2, however, possible negative impacts of antibodies could then be blocked with adequate treatment (ibid.). However, this would be again more pharmaceutical efforts to endeavour.

      The possible existence of such individuals that would then possibly be more fragile after infection needs to be thoroughly deepen and then checked before general measures are applied to the population.

      Length of the protective acquired immunity

      However, antibodies remain in the body, for a while (e.g. interviews with virologists and immunologists in Katherine J. Wu, “What Scientists Know About Immunity to the Novel Coronavirus“, Smithsonian Magazine, 30 march 2020; Callow, K A et al. “The time course of the immune response to experimental coronavirus infection of man.” Epidemiology and infection vol. 105,2 1990; Gaubert, Ibid.).

      But how long is this while? This is the first unknown we face. Antibodies usually diminish with time then disappear (Wu, ibid.). Thus, how long do we keep these antibodies? For how long will the acquired immunity be protective?

      Then, another related question is about the immune memory: will antibodies be able to remember the attacker well enough to generate the proper response (Wu, Ibid.)?

      Thus, to summarise, for our purpose the key question is: for how long will the acquired immunity be protective?

      Currently, although we do not know with certainty, most scientists seem to consider as likely hypothesis that, in general, patients who have recovered from the COVID-19 will be sufficiently immunised, for a while.

      The possible length of the naturally acquired immunity considered varies.

      Indeed, our knowledge of the SARS-CoV-2 is extremely recent. It started with recorded data mainly in January 2020. Thus at the beginning of April 2020, we cannot know with certainty the possible length of the immunity beyond 2 to 3 months. This is one more reason why monitoring what is happening in China, where the first patients recovered, is so important.

      Various hypotheses are considered.

      If the SARS-CoV-2 is similar to the coronavirus giving the common cold, then some scientists state that the immunity could last “years” (Interview with Angela Rasmussen, a virologist at Columbia University in Brian Resnick, “The 9 most important unanswered questions about Covid-19“, Vox, 20 March 2020). However, other results, obtained with the coronavirus 229E, show a more complex picture, as some individuals could also, in experiment, become reinfected a year later (Callow, K A et al. “The time course of the immune response to experimental coronavirus infection of man”, Epidemiology and infection, vol. 105,2, 1990).

      If the coronavirus behaves as the seasonal flu, the hypothesis the Imperial College COVID-19 Response Team used, then re-infection is considered as “highly unlikely in the same or following season” (Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand, 16 March 2020, p. 4). However, the seasonal flu is not a coronavirus.

      Other uncertainties

      The condition and age of the patient, as well as genetics, may also impact the response of the immune system (Wu, Ibid.).

      Finally, mutations may occur as the virus duplicates itself, leading to new strains the body cannot recognise, as with the seasonal flu (Wu, Ibid.). This is however less likely for coronaviruses than for flu viruses (Ibid.). But coronaviruses can also “trade segments of their genetic code with each other”, which allows them to trick the immune system. (Ibid.). In that case, the acquired immunity would be useless. Note that this would also be true for a vaccine.

      Virologists and immunologists most probably have other much more specific questions to which they need to find answers.

      Thus, with such a new disease, we are still faced with many uncertainties. How can we handle them?

      Impacts on the architecture of scenarios

      Again, scenarios are a crucial tool to handle these uncertainties.

      Our scenario structure is currently as follows. The main scenario we consider as most likely is that we shall have to wait for a vaccine until winter 2022 (at best) (see Hélène Lavoix, The COVID-19 Pandemic – Surviving and Reconstructing, The Red (Team) Analysis Society, 24 March 2020, last updated 3 April 2020). Then we need to account for the possibility to see the emergence of treatments impacting the disease (see Hélène Lavoix, Covid-19 – Scenarios – Making Sense of Antiviral Treatment, The Red (Team) Analysis Society, 30 March 2020).

      Now, ideally, we would need to have another epidemiological layer of models and scenarios that vary to include various possibilities for the acquired immune response. We would build the next layer of our scenarios out of these.

      Until such detailed epidemiological models are available, if ever, we need to handle the variable “immunity” as correctly as possible, through different sub-scenarios useful for our purpose. The best way at this stage is to consider a first batch of sub-scenarios where a fully protective immunity is developed upon recovery and to have this immunity vary according to time.

      Considering that the detailed epidemiological model that many governments use is the model the Imperial College COVID-19 response team developed (Ibid.), it is interesting for our purpose to look at a scenario that is less optimistic than the “same season and next one” immunity they used, for example less than one year, one that is the Imperial College scenario and one that is more optimistic, for example, an immunity that lasts from one and a half to two years.

      That said, the Imperial College’s model shows that “temporary suppression” (with social distancing of the entire population, case isolation, household quarantine and school and university closure) is the only way forward not to overwhelm the health system and to prevent massive fatalities. It also shows that because this suppression is successful, then only a small number of individuals will develop immunity. Hence, for a collective approach focused necessarily on health, fatalities and not overwhelming the health system, variations on the acquired immunity, because they play on small numbers, may not be a key variable.

      Things are, however, more challenging for the second objective all polities must fulfil, i.e. ensuring the fundamental security a society needs to survive as well as not to break down (see The COVID-19 Pandemic – Surviving and Reconstructing, and Summary of previous findings in Covid-19 – Scenarios – Making Sense of Antiviral Treatment). Indeed, critical functions must continue, and, as much as possible, a new economy must start emerging. As a reminder, the first objective is to reduce as much as possible the fatalities resulting from the disease (see Summary of previous findings, ibid.).

      Hence the need for sub-scenarios that consider acquired immunity and its length.

      Finally, to make sure we cover the whole range of possible futures, we may create a “complex immunity” scenario that would actually cover all other cases. This scenario would, for example, include a situation where the acquired immunity varies so much according to diverse criteria that it becomes difficult, rapidly, to create adequate understanding and thus policies. It could also be used if our knowledge is so uncertain and the involved risks are so high that similarly, no policy can be created easily. With time, or according to the decision-makers for whom the actionable scenarios are created, this “cluster scenario” would need to be developed adequately.

      This “complex scenario” would be the least favourable.

      Immunity and exit strategy

      We must highlight first that the theories and models created to handle the exit of the “suppression/isolation” period need to account for the immunity uncertainty.

      Thus, considering the high cost in lives and sufferings, as well as the impacts across domains, we must consider all scenarios. We cannot consider only the most likely and most preferable scenario. Actually, we need either to make sure that policies will be correct across scenarios or that they are flexible enough to switch in a timely way from one scenario to another. In that case, this demands precise monitoring and warning that will allow to steer policies, again in a timely manner. This flexibility should also allow to fully integrate new understanding and new results on the length and protection of the acquired immunity, as they become known.

      Policies also need to be correct at both individual and collective level, considering the high stakes in terms of legitimacy for political authorities. For example, the policies should try to consider the possibility of individual variations in terms of acquired immunity.

      In terms of exit strategy, for example, the current assumption, considering the early results (see above) is that people who were positive to the COVID-19 and recovered, now have a protective immunity to the SARS-CoV-2. However, it does not seem that the length of the immunity is, so far, taken into account.

      The challenge thus becomes, in terms of handling of the pandemic and exit of the isolation/suppression phase to identify who has antibodies. If we wanted to also make sure the length of the immunity is considered, then we would need to make sure that a possible fading of the immunity can be identified.

      The answer to this need will be in the serological tests, which are currently developed worldwide (Chad Terhune, Allison Martell, Julie Steenhuysen, “U.S. companies, labs rush to produce blood test for coronavirus immunity“, Reuters, 25 March 2020; Gretchen Vogel, “New blood tests for antibodies could show true scale of coronavirus pandemic“, Science, 19 March 2020; Hugo Jalinière, “Les tests de sérologie, clé du déconfinement“, Sciences et Avenir, 30 mars 2020; Lauren Chadwick, “Coronavirus: Antibody tests ‘will be crucial’ in determining when to lift lockdowns“, Euronews, 6 April 2020; for a list of commercially developed tests all categories, not only serological, see Find, Covid-19 Diagnostics resource centre).

      Assuming that the tests are reliable, we nonetheless find again the familiar problem of quantities. The ongoing “war for face masks” is very likely to be again reproduced, this time, with tests. Masks as well as serological tests become crucial stakes to fulfil the two objectives of societies faced with the COVID-19 pandemic. Those who will be able to develop and secure for their populations as much and as many of the necessary tools – including smart strategies – to both survive and ensure the fundamentals of security, will survive best. Furthermore, they are also likely to be earlier and better able to interact again with each other.

      To account for the length of the immunity, if the tests which are developed cannot detect early enough a fading of immunity, then testing many times subjects may become necessary. However, here the problem of test quantity – and test operationalisation – increases. Continuing imperatively protective gestures as well as a generalisation of face masks is thus likely to be necessary to compensate for insufficient serological testing.

      With the next articles we shall continue exploring the factors which are key to build the general architecture of our scenarios.

      Some detailed references and bibliography

      Callow, K A et al. “The time course of the immune response to experimental coronavirus infection of man.” Epidemiology and infection vol. 105,2 (1990): 435-46. doi:10.1017/s0950268800048019

      Linlin Bao, Wei Deng, Hong Gao, Chong Xiao, Jiayi Liu, Jing Xue, Qi Lv, Jiangning Liu, Pin Yu, Yanfeng Xu, Feifei Qi, Yajin Qu, Fengdi Li, Zhiguang Xiang, Haisheng Yu, Shuran Gong, Mingya Liu, Guanpeng Wang, Shunyi Wang, Zhiqi Song, Wenjie Zhao, Yunlin Han, Linna Zhao, Xing Liu, Qiang Wei, Chuan Qin, “Reinfection could not occur in SARS-CoV-2 infected rhesus macaques“, bioRxiv, 14, March 2020, 2020.03.13.990226; doi: https://doi.org/10.1101/2020.03.13.990226

      Thevarajan, I., Nguyen, T.H.O., Koutsakos, M. et al. Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19. Nat Med (2020).https://doi.org/10.1038/s41591-020-0819-2

      Shi, Y., Wang, Y., Shao, C. et al. COVID-19 infection: the perspectives on immune responses. Cell Death Differ (2020). https://doi.org/10.1038/s41418-020-0530-3

      Featured image: Image par Gerd Altmann de Pixabay

      COVID-19 Antiviral Treatments and Scenarios

      The world is now struggling to know how to face the COVID-19 pandemic. We want to know how long the pandemic will last. Actually, what we want to know is when the pandemic will end and when life will be able to resume normally.

        As we explained in the opening article for this series, to be able to answer these questions, considering the very high number of uncertainties involved, we need to use scenarios. Our aim is to contribute to the creation of robust scenarios in our field, political science and international relations. We are thus concerned with the future of polities, i.e. the futures of organised societies. Nonetheless, to be able to do so, we obviously have to take into account what other sciences, those primarily concerned with diseases and pandemics, find out.

        For now we are trying to establish both the general structure for our scenario tree and the timeframe. Thus we study main critical factors that will allow us to articulate our scenarios.

        In this article, we first briefly summarise the points made in previous articles. We then turn to the antiviral prophylaxis and treatment as a second key critical factor.

        Summary of previous findings

        Objectives of societies faced with a pandemic

        Because we have collectively and individually “chosen” not to accept the baseline worst case scenario, then our main aim is now survival for each individual, and for each polity, society or country. Fundamentally, as long as the pandemic continues, thus as long as the baseline worst case scenario could become a reality, each polity will need to fulfil simultaneously two objectives.

        First objective

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        The first objective is to reduce as much as possible the fatalities resulting from the disease. This implies reducing the number of infected people and caring for those who are ill. This means, in turn, not overwhelming the care system.

        Should we fail, then, not only the dreaded scenario we seek to avoid would take place, but, at worst, all other fatalities and deaths we succeeded to prevent over centuries could come back. The excess deaths (compared with the pre-pandemic time) would be dramatic. It would also seriously impaire the capacity of a society to ensure its security and, at term its survival.

        Second objective

        The second objective is to continue having a society that ensures fundamental security.

        Simultaneous objectives

        The two aims must be fulfilled at the same time.

        Indeed, if fundamental security is not ensured, then the system will rapidly collapse. Neither caring for diseased people, nor containment measures will be possible anymore. The pandemic will run its course as with the worst case scenario, but the situation will be even worse. If we do not stop the pandemic, then death and disease will take their toll and damage the capacity of society to ensure its security. Society will be fragilised, and in turn will less be able to handle the pandemic, increasing fatalities. We risk here to fall into a vicious circle.

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        Immunisation and vaccine as a first key critical factor

        We explained in the previous article, that immunisation through vaccination is a first critical factor around which we can organise the architecture of our scenarios. We also assessed – with many uncertainties remaining – that we could not expect such immunisation to take place before winter 2022-2023. This gives us a first broad likely scenario upon which we can concentrate. Within this scenario that we shall use as framework, we need to understand the futures of our systems as they face the COVID-19 over the next two to three years.

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        Actually, another implicit scenario at the same level of analysis should also be made explicit. This scenario is, however, uncontrollable, according to the current and expected stage of knowledge. The virus, could lose either its infectious power or its lethality or a strong immunity could also develop naturally among human beings. In that case, the pandemic would end much earlier. This scenario being less likely and also obviously less threatening, considering limited resources, we shall not, right now, examine it. Nonetheless the factors influencing the probability of this scenario must be monitored.

        Antiviral prophylaxis and treatment – a second key critical factor

        Antiviral prophylaxis and treatment are a second critical factor for our scenarios architecture. Indeed, we try to reduce fatality. Thus, if we have a cure for the disease, the possibility of the worst case baseline scenario disappears.

        To date, 30 March 2020, there is no known antiviral treatment against the SARS-CoV-2, i.e. certain and having gone through all the usual testing process.

        Thus, some of the key questions we must ask are as follows. Is it possible to see a treatment discovered and developed? Which types of effects this treatment could have on the disease and on the pandemic? When could this treatment become available?

        Here, we face a supplementary challenge as controversies, debates, power and ego-struggles have entered the field. Meanwhile, notably out of fear, panic, or lack of trust in governments, these debates and struggles have been transformed and relayed as rumours, fake news, and conspiracy theories.

        As far as we are concerned, we shall rely on scientific papers and focus on looking for elements which are key for our aim, contributing to establish valid scenarios. We shall also keep the issue of the timeframe in mind.

        Possible candidate antiviral treatments from existing and known drugs

        The Chloroquine hope and debate

        Since mid-February and increasingly so as the pandemic spread, the efficiency of chloroquine, either as Chloroquine phosphate or as one of Chloroquine’s derivate, hydroxychloroquine, to treat patients infected with the SARS-CoV-2, has become a hot topic in scientific and lay publications (see a non-exhaustive bibliography below). Some promote it as the Graal that will save us all from the disease. Others just underline that the necessary clinical tests allowing to assert and measure its efficiency – as well as the ideal posology according to the stage of the disease – have not yet been completed. Meanwhile, conspiracy theories abound.

        Hope from a Chinese publication

        In a nutshell, the issue is relatively simple. On 19 February 2020, as an e-publication, Gao J, Tian Z, Yang X, published a letter for advanced publication titled “Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in
        clinical studies” in the journal BioScience Trends. There, they notably stated that

        “The drug is recommended to be included in the next version of the Guidelines for the Prevention, Diagnosis, and Treatment of Pneumonia Caused by COVID-19 issued by the National Health Commission of the People’s Republic of China for treatment of COVID-19 infection in larger populations in the future.”

        They also underlined that

        “results from more than 100 patients have demonstrated that chloroquine phosphate is superior to the control treatment in inhibiting the exacerbation of pneumonia, improving lung imaging findings, promoting a virus negative conversion, and shortening the disease course according to the news briefing”.

        The need for further trials

        Now, those who urge caution do so because they would like to have access to all these trials and to be able to replicate and enlarge them.

        Consequently, up to 30 March 2020, at least 17 studies (out of 22 trials) have started, or are planned, to carry out further testing of the efficiency of hydroxychloroquine on patients with COVID-19. They are taking place from South Korea to the U.S. through Thailand, Brazil and the EU. They address various stages of the clinical trials studying a drug. One of these studies only has been completed, in Shanghai. Its results have been published in the Journal of Zhejiang University (Medical Sciences, 3 March 2020). It was carried out only on 30 patients.

        Disappointing results on a small sample

        We should note that the results of the Shanghai’s trial show no impact of hydroxychloroquine on patients, compared with the control group. Even worse, although on such a small group conclusions are only tentative, one patient under hydroxychloroquine developed to a severe condition (ibid).

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        A French microbiologist promotes the treatment

        Meanwhile, some French immunologists and specialists in microbiology headed by the Director of the State Institut Hospitalo-Universitaire Méditerranée (IHM) Infection Didier Raoult promoted the early use of Chloroquine (Philippe Colson , et al., “Chloroquine and hydroxychloroquine as available weapons to fight COVID-19”, International Journal of Antimicrobial Agents, 26 February 2020). Furthermore, the same team tested Chloroquine with Azythromycine on 26 patients, 16 others being used as control group (Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label non‐randomized clinical trial). On 22 March 2020, they decided to start applying hydroxychloroquine massively to infected people in Marseille, adding furthermore Azythromycine.

        Out of the 17 studies mentioned earlier, three of them test the combination of Hydroxychloroquine and Azythromycin.

        Further need to be careful

        Meanwhile, scientists, including from the IHM, have warned about the difference between in vitro successful experiments and in vivo ones. For example, Franck Touret et Xavier de Lamballerie in “Of chloroquine and COVID-19” (Antiviral Research 177 (2020) 104762) pointed out various negative possible impacts in previous attempts at using Chloroquine on other types of viruses. Notably, “in a nonhuman primate model of CHIKV infection”, the use of Chloroquine was shown to delay the cellular immune response (Ibid.). Even though every virus is different, these earlier trials on other viruses highlight the need for caution.

        An indication from outside the medical world

        To this, we should add an indication coming from outside the world of clinical tests. If China considers “the apparent efficacy” of Chloroquine since 19 February, it has nonetheless continued its lockdown, travel bans and quarantine policy on the country. Indeed, for example, lockdown on Wuhan will be partially lifted only on 8 April 2020 (BBC News, “Coronavirus: Wuhan to ease lockdown as world battles pandemic“, 24 March 2020). Furthermore, China is rightly being extra careful with not allowing new imported cases to spread (BBC News, “Coronavirus travel: China bars foreign visitors as imported cases rise“, 27 March 2020). It is paying particular attention to all cases, in case a new wave of COVID-19 would hit the country (Ibid).

        Should Chloroquine – possibly added to Azythromycine – be such a miracle drug, then China would not be so afraid of seeing a new epidemic outbreak. Thus, if we take Chinese policies and behaviour as indication, Chloroquine could hopefully alleviate sufferings, but not critically change the disease behaviour.

        The results of the clinical trials will tell.

        Other candidate treatments

        Meanwhile, China and other countries are testing other drugs and molecules, such as arbidol, remdesivir, favipiravir, lopinavir and ritonavir, also with immunomodulator interferon beta-1b and others (Liying Dong, Shasha Hu, Jianjun Gao, Discovering drugs to treat coronavirus disease 2019 (COVID-19), Drug Discov Ther. 2020;14(1):58-60. doi: 10.5582/ddt.2020.01012; Lindsey R. Baden, M.D., and Eric J. Rubin, M.D., Ph.D., Covid-19 — The Search for Effective Therapy, NEJM, 18 March 2020; Camille Gaubert, “Coronavirus : lancement d’un essai clinique sur 3.200 patients atteints de Covid-19“, Sciences et Avenir, 12 March 2020; John Cahill, “Potential COVID-19 therapeutics currently in development“, European Pharmaceutical Review, 26 March).

        Major ongoing trials

        Among all these candidates the WHO has selected four treatments as most promising for a very large trial: the “experimental antiviral compound called remdesivir; the malaria medications chloroquine and hydroxychloroquine; a combination of two HIV drugs, lopinavir and ritonavir; and that same combination plus interferon-beta” (Kai Kupferschmidt, Jon Cohen, “WHO launches global megatrial of the four most promising coronavirus treatments“, Science, 22 March 2020). The WHO solidarity trial is expected to run from March 2020 to March 2021 (ISRCTN registry).

        The French INSERM coordinates a European corresponding trial called DISCOVERY on 3200 patients. It started on 22 March. Fifteen days after the inclusion of each patient, the analysis of treatment efficacy and safety will be evaluated.

        We should also count the Institut Hospitalo-Universitaire Méditerranée 22 March beginning of treatment of patients with Chloroquine and Azythromycine also as a trial. Indeed, it differs from SOLIDARITY and DISCOVERY because it adds Azithromycine. This point could be important if we consider the pre-test done, as Azythromycine seemed to have a critical role to play (Ibid.).

        As highlighted above, according to the database Clinicaltrials.gov of the U.S. government, 22 trials are currently taking place on various drugs.

        Discovering new treatments or uncovering less common treatments

        This type of scenario is quite similar, in terms of process, to what we saw with vaccines. We must first discover or unearth one or more molecules that may positively impact the development of the disease, yet without adverse effects.

        Artificial Intelligence, Automation, and supercomputers against the SARS-CoV-2

        As existing and known drugs and treatments are tried, researchers are also also busy trying to unearth or discover molecules that could help fight the SARS-CoV-2.

        For example the Institut Pasteur of Lille – France (EN version) tests molecules on the virus thanks to robots in a specially confined laboratory. As a result, researchers can greatly speed the rhythm of tests. Thousands are carried out daily. Meanwhile, the combination of molecules by pairs for testing is also automated (website).

        DeepMind, or rather DeepMind Technologies Limited, the famous artificial intelligence / deep learning lab. Alphabet Inc. (Google) bought, joined the efforts to fight the SARS-CoV-2 ( Computational predictions of protein structures associated with COVID-19, 5 March 2020 – for more on artificial intelligence and deep learning see our related series). It used the latest version of their AlphaFold system to “release structure predictions of several under-studied proteins associated with SARS-CoV-2”. Should these deep learning predictions then be confirmed through experiments, then they will have contributed to a better knowledge of the virus and possibly to the development of new drugs.

        Researchers at the U.S. Oak Ridge National Lab (Department of Energy) use Summit, the most powerful supercomputer to date, “to run through a database of existing drug compounds to see which combinations might prevent cell infection of COVID-19” (Brandi Vincent, “Researchers at Oak Ridge National Lab Tap into Supercomputing to Help Combat Coronavirus“, Nextgov.com, 11 March 2020). Researchers could simulate 8,000 compounds and select 77 that have “the potential to impair COVID-19’s ability to dock with and infect host cells” (Dave Turek, “US Dept of Energy Brings the World’s Most Powerful Supercomputer, the IBM POWER9-based Summit, Into the Fight Against COVID-19“, IBM News Room, nd). It took them a couple of days instead of “months on a normal computer” (Ibid.).

        As we pointed out in our series on supercomputers and computing power, these are increasingly key factors for the present and the future. In this case, supercomputers could be critical in the fight against this pandemic.

        Other efforts using supercomputing power, such as a NSF programme or the European program Exscalate4CoV are at work (Oliver Peckham, “Global Supercomputing Is Mobilizing Against COVID-19“, 12 March 2020, HPC Wire). For example,

        “E4C is operating through Exscalate, a supercomputing platform that uses a chemical library of over 500 billion molecules to conduct pathogen research. Specifically, E4C is aiming to identify candidate molecules for drugs, help design a biochemical and cellular screening test, identify key genomic regions in COVID-19 and more”. 

        Oliver Peckham, “Global Supercomputing Is Mobilizing Against COVID-19“, 12 March 2020, HPC Wire

        We could also imagine that companies and start-ups in the quantum information science field, who highlighted the importance of quantum computing and simulation in the field of chemistry, for example, or material science, would be actively contributing to the fight against the COVID-19 (e.g. Foreseeing the Future Quantum-Artificial Intelligence World and Geopolitics; Quantum Optimization and the Future of Government). A similar point could be made regarding logistics necessary to survive the pandemics, working from the Volkswagen Group research with D-Wave (Quantum Optimization, Ibid.). Yet, up to 30 March 2020, no open source information regarding the participation of the “quantum world” in the fight against the COVID-19 seems to be available.

        When could such a new treatment become available?

        There is no way to know how close we are to the discovery of the right molecule or combination of molecules.

        Once it is discovered, the new potential drug will have to go through the whole process of trial and development, including clinical trials (e.g. EU Drug Discovery and Development, U.S. Biopharmaceutical Research & Development).

        Classically – i.e. when we are not in an emergency mode – this process takes 10 to 15 years (Drug discovery, Ibid.) as shown in the picture below.

        EU Drug Discovery and Development, p.11.

        Then, even if we are lucky and manage to shorten the process – to how long? – we shall still need to manufacture the drug and then deliver it.

        First, this explains why the current focus is on known drugs. Second, this highlights that totally new drugs may not help us on the short and even medium term.

        This reminds us that major world pandemics, in the past, lasted not months, but years. Meanwhile, outbreaks happened across centuries. If ever, for antiviral treatments, hope is only in the discovery of a totally new medicine, then then waiting (actively) for a vaccine moved from being a pessimistic scenario to being an optimistic scenario.

        Key elements to look for in an anti SARS-CoV-2 treatment and to inject in scenarios

        Because an antiviral treatment can mix different drugs, posologies and approaches, sub-scenarios will need to include main elements impacting epidemiological models. To identify them, we used the model of the Imperial College COVID-19 Response Team in Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand, 16 March 2020. As a result, we shall also get the indicators we need to monitor candidate treatments.

        We assume that, once a treatment is found, epidemiologists will relatively rapidly run their models and publish results. In turn, this will allow us updating our scenarios as well as their likelihoods.

        The key elements to which we need to pay attention are as follows.

        Impact on infectiousness

        For example, the treatment could be given prophylactically to everyone, or to the contact cases of an infected person. In turn, the treatment could also lower the cases of asymptomatic or very mild symptomatic infections.

        Impact on immunity

        The impact of treatment on immunity after recovery from infection, on the short term and on the long-term needs to be evaluated.

        Impact on severity of disease

        If the treatment is given to symptomatic cases, we shall monitor if the treatment lowers the amount of patients developing severe, critical and fatal disease. This could twice decrease the pressure on the health system. Indeed, we would have less patients needing stays in hospitals. Furthermore, the duration of the stay in hospital could also diminish. Currently, the Imperial College COVID-19 Response Team estimates that we have:

        “A total duration of stay in hospital of 8 days if critical care is not required and 16 days (with 10 days in ICU) if critical care is required. With 30% of hospitalised cases requiring critical care, we obtain an overall mean duration of hospitalisation of 10.4 days…”

        Imperial College COVID-19 Response Team, Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand, 16 March 2020

        Manufacturing and supply

        Again, as for vaccine, the manufacturing of doses and their availability per country will need to be envisioned in detailed scenarios. Supply tensions are likely to emerge. As a result, we may possibly face international tensions. Should the quantity of the new drug be insufficient per country, then it would be interesting if epidemiological models were run according to possible supply.

        New treatment(s) against the SARS-CoV-2 could offer any combination of the proprieties above. Ideally, epidemiological models or those built on them would also account for the feedbacks between non-pharmaceutical interventions, new treatments beneficial impacts and drug availability.

        With the next articles, we shall continue to explore the factors that determine the architecture of our scenarios.

        Bibliography

        Tara Haelle, “Chloroquine Use For COVID-19 Shows No Benefit In First Small—But Limited—Controlled Trial“, Forbes, 25 marche 2020.

        Tony Y. Hu, Matthew Frieman & Joy Wolfram, “Insights from nanomedicine into chloroquine efficacy against COVID-19“, Nature, 23 March 2020.

        Xueting Yao, Fei Ye, Miao Zhang, Cheng Cui, Baoying Huang, Peihua Niu, Xu Liu, Li Zhao, Erdan Dong, Chunli Song, Siyan Zhan, Roujian Lu, Haiyan Li, Wenjie Tan, Dongyang Liu, In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), Clinical Infectious Diseases, , ciaa237, https://doi.org/10.1093/cid/ciaa237

        Adam Rogers, Chloroquine May Fight Covid-19—and Silicon Valley’s Into It, Wire, 19 March 2020.

        Liu, J., Cao, R., Xu, M. et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Nature, Cell Discov 6, 16 (2020), 18 March 2020. https://doi.org/10.1038/s41421-020-0156-0

        Philippe Colson, Jean-Marc Rolain, Jean-Christophe Lagier, Philippe Brouqui, Didier Raoult, “Chloroquine and hydroxychloroquine as available weapons to fight COVID-19“, International Journal of Antimicrobial Agents (2020), doi: https://doi.org/10.1016/j.ijantimicag.2020.105932

        Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label non‐randomized clinical trial. International Journal of Antimicrobial Agents – In Press 17 March 2020 – DOI : 10.1016/j.ijantimicag.2020.105949.

        Guangdong Provincial Department of Science and Technology and Guangdong Provincial Health Committee Multi-center Collaborative Group on Chloroquine Phosphate for New Coronavirus Pneumonia, “Expert Consensus on Chloroquine Phosphate for New Coronavirus Pneumonia” [J]. Chinese Journal of Tuberculosis and Respiratory Medicine, 2020,43 (03 ): 185-188. DOI: 10.3760 / cma.j.issn.1001-0939.2020.03.009

        Featured image: Image by Darko Stojanovic from Pixabay 

        The COVID-19 Pandemic, Surviving and Reconstructing

        The COVID-19 pandemic is now a global fact. It still involves many uncertainties. At present and in the near future, we need to handle the ongoing pandemic as a global catastrophic crisis with complex cascading impacts. We also need to start thinking about reconstruction. We are here concerned with reconstruction that will allow polities to fully function again, i.e. not to be in emergency mode. That may go from norms to socio-political systems, through ways to produce goods and services. It may be elements of these systems, or larger parts of them.

          In this article, we explain first that we have tools to plan ahead properly and constructively even considering the condition of utter uncertainty. We must not allow the unpreparedness disaster that is also striking us to go on. Unpreparedness, resulting from lack of anticipation, must also stop.

          We then turn to the real issue we need to consider: surviving and reconstructing. We thus outline our research question and our scope. We explain that we are coming back to the fundamentals of politics (and not politician politics). We start outlining how both surviving and reconstructing are intertwined. As a result, we paint a sketch of what is ahead and what we need to further research.

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          Finally, we start the construction of a structure for our set of scenarios that will outline the possible futures. We underline that two factors are critical and will determine our future: vaccine and antiviral prophylaxis and treatment. Here we focus on the first of this factor, vaccine. We do not only look at the discovery of the right vaccine for the COVID-19 but also at the various stages of the immunization process. As a result, we obtain a first estimate that mass campaigns of vaccination may start earliest around winter 2022-2023 (all vaccine candidates). The next article focuses on antiviral prophylaxis and treatment.

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          Considering the very large scope of the task ahead, this article is the first of a series of articles focusing on strategic foresight and anticipation to survive at best the COVID-19 and then reconstruct.

          Tools to stop unpreparedness

          To be able to achieve the goals of surviving (across domains) and reconstructing, we need to deploy and use, at the same time, monitoring for warning and strategic foresight. And this is NOT an option but a crucial necessity.

          Monitoring for adequate models and to struggle against deadly biases

          Monitoring must take place in two areas. First, we must monitor what is happening in science, across many disciplines. Then, we must also consider what is happening on the ground. This monitoring will allow revising a knowledge that is everyday checked, changed, and improved.

          With the result of our monitoring, we shall need to update all our models, including those implicit models we use everyday and which are active, unknowingly, in our heads. Indeed, if we do not do that, these inner models will become cognitive biases. And cognitive biases, when survival is at stake, can be deadly.

          This part is extremely challenging because we know that human beings are naturally bad at updating the inner models that allow them to understand the world (e.g. Heuer, Richards J. Jr., Psychology of Intelligence Analysis, Center for the Study of Intelligence, Central Intelligence Agency, 1999 – more in our online course 1 – Module 3).

          For example, as shown by Anderson et al., if we are presented with a new problem and do not have a lot of information about it, our brain creates a first very approximative model. That model makes sense of whatever data we have (Craig A. Anderson, Mark R. Lepper, and Lee Ross, Perseverance of Social Theories: The Role of Explanation in the Persistence of Discredited Information, Journal of Personality and Social Psychology 1980, Vol. 39, No.6, 1037-1049).

          Then, once this model is created, it becomes very difficult to change it. Effort is necessary to do so. In other words, most people, will stick to their initial model, even though new facts and evidence arise. It is not that they lie or that they show bad will, although this, of course, may also happen. It is that those people had first to make sense of a new problem with insufficient information. As they receive new information, their model has become inadequate but it still filters their understanding (Craig A. Anderson et al. ibid.).

          Unfortunately, the COVID-19 pandemic exactly corresponds to the worst possible case to generate this kind of cognitive bias. We have the emergence of a new virus, then a completely new pandemic situation, with completely novel cascading impacts. We are thus in the perfect situation to see outdated inner cognitive models wreck havoc on a situation that is already catastrophic.

          Thus, we absolutely need to apply all methodologies that help us overcome the use of outdated models. Explicit modelling and methodologies of strategic foresight and warning including monitoring are crucial here.

          We must all learn to handle uncertainty

          Strategic foresight and notably scenarios, furthermore, can help us handling uncertainties when they remain.

          Indeed, modeling and scenario-building are the methodological tools epidemiologists use (e.g. for a recent and very influential study, Imperial College COVID-19 Response Team, Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand, 16 March 2020). And we, as social scientists, risk managers and decision-makers, must also follow suit and use this approach.

          Meanwhile, the range of responses we deploy must also, ideally, be as quick and flexible as possible. This is challenging, but this is possible.

          Even small businesses can do it. One way forward, in terms of capabilities, could be to mutualise some parts of the work, for example within chambers of commerce, or professional associations.

          Even individuals can and should do it. Indeed, in a pandemic, they are those who are first on the front line. The need to care and protect first and foremost the medical staff is constantly highlighted. This is, of course, indispensable. Each profession that participates in activities crucial for survival is key.

          Yet, alongside them as professional groups, those who fight on the front line are each and every individual, their body and their understanding of the situation. They are those who will stop or not the contagion. And they are those who will win against the virus or not.

          Framing our issue – surviving then reconstructing

          Rediscovering survival matters

          We have moved from a normal type of life and system to an emergency one, where only survival matters.

          The reasons for this move, despite the many conspiracy theories and denials of all sorts spreading, is grounded in the risks entailed by what we called crude worst case baseline scenarios. This is the epidemiological approach where overall possible fatalities are estimated, before scenarios to handle the pandemic start being modelled (e.g. Imperial College COVID-19 Response Team, Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand, 16 March 2020). We thus shall not come back to this point here.

          Thus, we have become aware again of the importance of survival as prime motivation. We are living the essence of what politics is really about: human beings are organised in society to survive, and the fundamental mission of political authorities is to ensure their survival and security (e.g. What is Political Risk? and related bibliography). Most people had forgotten these essentials, but the pandemic reminded us powerfully and pitilessly of these fundamentals.

          If you think about it, what we are all living through is absolutely extra-ordinary. Country after country, in a couple of days, according to cases, we went from a business as usual state (for those who were not paying attention to the world) to complete confinement, end of economic supremacy, closed borders, end of freedom, end of “fun”. And 168 countries face, one after the other, the same ordeal in a couple of months. And we see it and communicate about it across vast distances. This is completely new too.

          Destruction and reconstruction

          Meanwhile, and as a result, the usual pre-COVID-19 system is being destroyed.

          The scope, magnitude and depth of the destruction will depend upon how long the COVID-19 state of emergency system will last, upon the lethality and the amount of sufferings the pandemic will inflict on the population. It will also depend, relatedly, on the way the pandemic and the COVID-19 emergency system are handled and the resilience of the pre-COVID system.

          The reconstruction, in turn, will depend upon what “part” of the pre-COVID-19 world as a socio-ideological and political system has been destroyed and how this destruction was carried out. It will be determined by the amount of damages and sheer destructions the pandemic directly caused. The state of the various actors at the end of the pandemic, i.e strength, capabilities, intentions, trauma etc., will also, and as strongly, influence reconstruction.

          The case of face mask shortages

          For example, what the populations and their ruling authorities live, the intractable hurdles and fear they face, will remain as a burning mark in their memories. Those will certainly strongly shape their future decisions and actions.

          For instance, the whole of Europe and the U.S. face an incredible shortage of face masks (e.g. Yanqiu Rachel Zhou, “The global effort to tackle the coronavirus face mask shortage“, The Conversation, 17 March 2020; Keith Bradsher and Liz Alderman, “The World Needs Masks. China Makes Them — But Has Been Hoarding Them“, 13 March 2020, updated 16 March, The New York Times).

          This results from past mismanagement and from intense outsourcing of face mask manufacturing capabilities, notably to China that produces half of them (Ibid.; Fabien Magnenou, “Coronavirus : pourquoi la France manque-t-elle de masques de protection respiratoire ?“, France Info, 19 March 2020).

          Consequently, the non-producers must wait on others’, and notably China, good will and benevolence and gifts. They must wait until exports become available again.

          Thus, new production capabilities must be recreated from scratch, in a hurry, thanks to imagination, courage and good will, while the know-how must be reinvented. Adequate materials may lack. At the beginning, the resulting products may not be as safe as needed (e.g. Juliette Garnier, “Coronavirus : mobilisation générale pour fabriquer des masques en tissu“, Le Monde, 17 March 2020).

          In the meantime, the contagion spreads and people die. On the bright side, innovation and new ways to produce will emerge from this struggle for face masks.

          Yet, the stress and the fatalities and the fear will certainly not be forgotten in our lifetime and maybe for generations. As a result, it is very likely that major outsourcing to China or elsewhere is over, especially for goods that could be of critical importance.

          To come back to our main question, we are thus faced with a twin task. We must foresee the near future to be able to survive while, in the same time, identifying various scenarios of destruction and nascent reconstruction. Then, building from and upon this first layer, we must foresee possible ways to reconstruct.

          Looking for a first structure for our set of scenarios

          On the importance of time

          As a preamble, we need to stress a supplementary challenge we face when building the architecture of our set of scenarios for the COVID-19 pandemic.

          We need to introduce a relatively precise timeframe. Indeed, the length of time during which the pandemic will last, as well as the timing and duration of measures taken does matter. This is obvious when looking at epidemiological studies, which will be one of the main materials upon which we shall build (e.g. Imperial College COVID-19 Response Team, Ibid.; Joseph T Wu et al. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study, The Lancet, 31 January 2020).

          Key critical factors: vaccine and antiviral prophylaxis and treatment

          The first factor that determines all the others is the existence – or rather in our case the non-existence – of vaccine and/or antiviral prophylaxis and treatment. Once either vaccine or treatment or both are viable, then a second key question is their availability in sufficient quantity where they are needed. Finally, we have the operationalisation of mass vaccination and/or treatment. These elements are absolutely critical.*

          Indeed, once a vaccine will have become widely available and will have immunised the population, then the pandemic will end. In the case of treatments, we shall have potentially more variations and shades, but, fundamentally, the way the factor operates will likely be similar. We shall refine this statement after analysis.

          The scientific effort to identify possible vaccines candidates and antiviral prophylaxis and treatment is considerable. This could take place thanks notably to very early Chinese efforts to “sequence the genetic material of Sars-CoV-2” and willingness to share it as quickly as possible (e.g. Wu, F., Zhao, S., Yu, B. et al. A new coronavirus associated with human respiratory disease in China. Nature 579, 265–269 (2020), 3 February 2020; updated GenBank “SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) Sequences“; Laura Spinney, “When will a coronavirus vaccine be ready?“, The Guardian, 13 March 2020).

          We should, however, note – for the next pandemic – that time has been lost those last years and notably since the SARS 2003 epidemic. Indeed, “medication against coronaviruses” were not included in the progress made over the last 25 years in antiviral medication (interview of Matthias Götte, a biochemist and viral researcher from Hamburg in Kerstin Kullmann und Veronika Hackenbroch, “The Urgent Search for a Cure for COVID-19“, Der Spiegel, 13 March 2020).

          Vaccine

          Discovery matters

          Various companies, universities and research laboratories would currently be exploring between 15 (Pang et al., Feb 2020, see table on vaccines) and 35 vaccine candidates of various types (Laura Spinney, Ibid.). They are all in the early stages of the overall process (Ibid.; John Hodgson, “The pandemic pipeline“, Nature, 20 March 2020). By 15 April, more than 70 vaccine candidates would be explored, five being at the preliminary trials’ stage (Christine Soares, “The lifeline pipeline“, Reuters, 13 April 2020).

          For example, human trials have already started for U.S. Moderna Therapeutics’ candidate vaccine (Michelle Roberts, “Coronavirus: US volunteers test first vaccine“, BBC, 17 March 2020). In that case the animal trials have even been skipped (Ibid.). Other human trials will start in April 2020 (Spinney, Ibid.). French Sanofi is also working on a candidate vaccine (see below).

          Hodgson states that another candidate vaccine, developed by Singapore, would be at the manufacturing stage (Hodgson, Ibid.). This is probably an editing mistake, because after verification, the vaccine, developed with the Company Arcturus has not yet entered clinical trials. They expect to start phase 1 of clinical trials “in the third quarter of the year” and to complete it at the end of 2020 or beginning of 2021 (Joyce Teo, “Countries, including Singapore, in race to develop vaccine“, Straits Times, 25 March 2020). Thus, Singapore and Arcturus are nowhere near the manufacturing stage. However, Arcturus suggests that their manufacturing process will be quicker than for other vaccines (Arcturus website ibid.).

          Chinese CanSino Biologics Inc. has also started conducting first phase clinical trial, which should last until December 2020 (China embarks on clinical trial for virus vaccine, The Star, 22 March 2020).

          Manufacturing vaccin doses matters too

          In general, scientific studies estimate that we are at best between 10 and 18 months away from a vaccine (e.g. interviews in Spinney, Ibid.; Helen Stillwell, “SARS-CoV-2 – The vaccine landscape“, Virology Blog; 11 March 2020; Roy M Anderson et al., “How will country-based mitigation measures influence the course of the COVID-19 epidemic?” – The Lancet – Published online March 09, 2020). These studies however rarely mention which phase of the vaccination process is included in these 10 to 18 months.

          The director of the U.S. National Institute of Allergy and Infectious Diseases (N.I.A.I.D.) assesses that “the earliest it [a vaccine] would be deployable is in a year to a year and a half,” which would tend to imply that it has been manufactured by then (Carolyn Kormann, “How Long Will It Take to Develop a Coronavirus Vaccine?“, The New Yorker, 8 March 2020).

          For its part, the global head of vaccine research and development of Sanofi estimates that, at best “a vaccine could be fully ready for licensure in a year and a half.” (Ibid.) In that case, this means that the time to manufacture doses is not included in the year and a half. This may sound logical as without the composition of the vaccine, it may be hard to assess the time needed to produce it and in which quantities.

          As far as estimates of manufactured doses are concerned, the firm Inovio, for example has as target 1 million doses by the end of 2020 (Tarryn Mento, “Inovio Pharamaceuticals Fast-Tracking Human Trials, Working On 1 Million Doses Of Coronavirus Vaccine“, KPBS, 20 March 2020). This is only a target as its production capability by end of January 2020 was 100.000 doses a year (Jon Cohen, “Scientists are moving at record speed to create new coronavirus vaccines—but they may come too late“, Science, Jan. 27, 2020).

          Moderna could produce at best 100 million doses a year, but would use all its production capability for it (Cohen, ibid.). For another candidate vaccine, “the Queensland team says it could make 200,000 doses in 6 months” (Cohen, Ibid,).

          Sanofi, for the U.S., “has the established capacity and infrastructure to make up to 600 million doses in two existing facilities based in New York and Pennsylvania, without compromising the supply of vaccines for other illnesses, including influenza” (Sanofi, “Sanofi Mobilizes to Develop a Vaccine against COVID-19“, 23 march 2020). Meanwhile, on 23 March 2020, Sanofi confirmed its timeline: “We estimate that we will have a vaccine candidate available for in vitro testing within six months and potentially enter clinical trials within a year and a half” (Sanofi, “Sanofi’s Response in the Fight against COVID-19“, 23 march 2020).

          In he meantime, the 2017 created Coalition for Epidemic Preparedness Innovation (CEPI) is building up its capacity to produce “multiple millions of doses available within 12–18 months” (Hodgson, Ibid.).

          China vaccines manufacturers also now have massive capabilities to produce vaccines. In 2018, Yaming Zheng et al. estimated that China produced annually 700 million vaccine doses (The landscape of vaccines in China: history, classification, supply, and price. BMC Infect Dis).

          Global estimates of future production of vaccine doses remain quite elusive and will need to be handled through scenarios, waiting for further research.

          How long could the emergency or survival period last? A first estimate

          This first open source brief review gives us the guidelines to conduct further in-depth study and to define the monitoring that will need to take place. Indeed, we now have the material to identify at least a first batch of indicators to monitor to follow the situation on the ground.

          Meanwhile, each uncertainty related to the “vaccine factor” will create a sub-branch in our scenario tree. In other words, in the following paragraphs, each time I’ll make an assumption and use a word such as “imagine” or “if”, this means that we are dealing with sub-branches and sub-scenarios.

          Waiting for a finalised architecture for our scenario tree, we can already roughly outline a very optimistic scenario. This is a scenario where at least one current candidate vaccine goes successfully through all the trials, in 12 months. This brings us, for the start of the manufacturing process to March 2021.

          Here, we must remember that Singapore and those using a technology similar to Arcturus could produce more quickly the vaccines. However, the clinical trials must be successful first.

          Now, a 2018 presentation by the chair of RA WG at Vaccines Europe (a specialised vaccines group within the European Federation of Pharmaceutical Industries and Associations (EFPIA), the professional association of the pharmaceutical industry in Europe) gives 24 months for the overall vaccine manufacturing process, up to distribution (slide 6 – see below).

          2018 presentation by Michel Stoffel, chair of RA WG at Vaccines Europe

          Let us imagine – but further sub-scenarios will be necessary here actually – that efforts will be made and succeed at speeding up this process and reduce it to 20 months. This brings us to November 2022. And then a mass vaccination campaign must start. We shall leave this part aside for now, but it is nonetheless important to underline that a mass immunization campaign is not a small endeavour (e.g. WHO “Aide Mémoire – To ensure the efficiency and safety of mass immunization campaigns with injectable vaccines“)

          Here, we must wonder about the number of doses that need to be injected for immunization. We must wonder about the length of the immunization. If ever the SARS-CoV-2 mutates and changes every year, as with the flu, or if it does not, we have different scenarios in front of us.

          In the best of case, we can imagine that only one dose needs to be injected, and that immunization will last for years. We may also assume that herd immunity can be reached with only 70% of the population receiving the vaccine (a crude estimate of what is considered as necessary for the influenza, see, Kenneth A.McLean, Shoshanna ​Goldin, Claudia Nannei, Erin Sparrow, Guido Torelli, “The 2015 global production capacity of seasonal and pandemic influenza vaccine“,Vaccine, Volume 34, Issue 45, 26 October 2016, pp. 5410-5413; “Community Protection“, table in Paul E.M. Fine, … W. John Edmunds, in Plotkin’s Vaccines (Seventh Edition), 2018).

          In these conditions, as a crude approximation, we may need a production of 70% x 7,7 billion = 5,39 billion doses to immunize the world against the SARS-CoV-2.

          Various scenarios of collaboration and possible international tensions related to this production may thus also need to be built.

          In any case the evolution of the vaccine process must be closely anticipated and monitored for action as no nation and no government will be there able to afford a situation looking like what happened with face masks.

          As a conclusion, a first crude estimate of a best case scenario for the vaccine suggests that we shall have to wait until winter 2022-2023. This assessment includes many unknowns that we must handle through scenarios, monitoring and ongoing revision. Furthermore, completely unpredictable events, can also occur, such as a mutation of the virus towards less lethality for example, to be optimistic.

          We have progressed into building the overall structure of our scenario tree. We also have a timeframe. Meanwhile, this timeframe also tells us that we cannot sit and wait for a vaccine. At this very early stage of our work, the years ahead for the surviving system or surviving stage, will likely need to include a vast array of imaginative solutions, mixing isolation and lock down, new ways of organisation and production, improved personal protection, new technological capabilities such as artificial intelligence, and, critically, antiviral prophylaxis and treatment.

          We shall look next at main potential antiviral treatment including the chloroquine that generates so much hope (e.g. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Mar 12;43(3):185-188. doi: 10.3760/cma.j.issn.1001-0939.2020.03.009 “Expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia”; Jianjun Gao, Zhenxue Tian, Xu Yang, “Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies“, BioScience Trends, 2020, Volume 14, Issue 1, Pages 72-73, Released March 16, 2020, [Advance publication] Released February 19, 2020).

          *For vaccines, the 2017 created Coalition for Epidemic Preparedness Innovation (CEPI) identifies five steps: Discovery, Development /licensure, Manufacture, Delivery/stockpiling, Last mile.

          Further detailed bibliography

          Anderson, Roy M, Hans Heesterbeek, Don Klinkenberg, T Déirdre Hollingsworth, “How will country-based mitigation measures influence the course of the COVID-19 epidemic?” – The Lancet – Published online March 09, 2020

          Pang J, Wang MX, Ang IYH, Tan, SHX, Lewis RF, Chen, JI, Gutierrez RA, Gwee SXW, Chua PEY, Yan Q, Ng XY, Yap RKS, Tan HY, Teo YY, Tan CC, Cook AR, Yap JCH, Hsu LY, “Potential Rapid Diagnostics, Vaccine Therapeutics for 2019 Novel Coronavirus (2019-nCoV): A Systematic Review,” J. Clin. Med. (2020) 9(3), doi: 10.3390/jcm9030623 (received 13 February 2020 ).

          Wu, F., Zhao, S., Yu, B. et al. A new coronavirus associated with human respiratory disease in China. Nature 579, 265–269 (2020), 3 February 2020. https://doi.org/10.1038/s41586-020-2008-3.

          Thevarajan, I., Nguyen, T.H.O., Koutsakos, M. et al. Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19. Nat Med (2020). https://doi.org/10.1038/s41591-020-0819-2

          Zheng, Y., Rodewald, L., Yang, J. et al. The landscape of vaccines in China: history, classification, supply, and price. BMC Infect Dis18, 502 (2018). https://doi.org/10.1186/s12879-018-3422-0

          Featured image: Image by Gerd Altmann from Pixabay, Public Domain

          Worst Case Baseline Scenarios for the COVID-19 Pandemic

          On 11 March Chancellor Merkel warned that the SARS-CoV-2 – the virus for the COVID-19 – could infect between 60 and 70% of Germany’s population (DW, “Coronavirus: Germany’s Angela Merkel urges ‘solidarity and reason‘”, 11 March 2020). She was accused to spread panic (Ibid.). Chancellor Merkel’s point was to highlight the very real danger Germans faced.

          In this article, we explain why, indeed, as stressed by Chancellor Merkel, a pandemic such as the COVD-19 is something serious. We do so by establishing a crude baseline worst case scenario that helps us assessing the magnitude of the threat. The seriousness of the danger then determines why political authorities must consider the pandemic and why they need to take such drastic measures as complete lockdown of countries. Most importantly the severity of the threat determines actions and then real impacts. Meanwhile, we also explain how the rate Chancellor Merkel used was calculated.

          A threat to life primes any other concern

          Since the start of the pandemic, then still an outbreak, many commentators permanently try to minimize the possible extent of the threat. Rather than getting rational assessments and scenarios with acknowledgment of uncertainty and proper probability, we hear and read a vast array of comments and opinions most of them aimed at being positive, minimising problems, putting the economy first, while also often mocking others. As we pointed out earlier, this most probably stems also from the various interests of actors, added to many cognitive biases (see The Coronavirus COVID-19 Epidemic Outbreak is Not Only about a New Virus and The New Coronavirus COVID-19 Mystery – Fact-Checking).

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          Nonetheless, we must remember that the fundamental mission of political authorities is to ensure the security of those they rules (see What is Political Risk?). Meanwhile, and as fundamentally, individuals want to survive. Thus, when a very direct threat to life, such as a virus and its related disease, emerges and spreads, then, very rapidly, all other matters loose importance. Actually, the rapidity of the understanding of the magnitude of the threat will also determine the measures taken and the very actualisation of the threat.

          Thus, the problem is to evaluate the potential direct threat to life, at individual and collective level.

          How to evaluate the potential direct threat to life?

          Uncertainty and being careful with what we know through the Chinese experience

          Because the virus is new, and as all serious scientific actors dealing with the SARS-CoV-2 and the COVID-19 permanently stress, much is still unknown about both the virus and the disease.

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          Furthermore, most of what we know about the illness and its spread comes from China. It thus includes the way the Chinese handled the epidemic. Our current knowledge thus contains elements about the virus and the disease that can be universally applied, as well as, possibly, idiosyncrasies. We should not forget that China deployed gigantic means to face the epidemic (Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) – 16-24 February 2020). These means and actions influenced the way the disease “behaved”.

          They may also have influenced the virus itself. Indeed, and even though further research is needed, in an early study, Xiaolu Tang, Changcheng Wu, et al. found, studying the genomes of the SARS-CoV-2, that

          “… these viruses evolved into two major types (designated L and S) … Whereas the L type was more prevalent in the early stages of the outbreak in Wuhan, the frequency of the L type decreased after early January 2020. Human intervention may have placed more severe selective pressure on the L type, which might be more aggressive and spread more quickly. On the other hand, the S type, which is evolutionarily older and less aggressive, might have increased in relative frequency due to relatively weaker selective pressure.”

          Xiaolu Tang, Changcheng Wu, Xiang Li, Yuhe Song, Xinmin Yao, Xinkai Wu, Yuange Duan, Hong Zhang, Yirong Wang, Zhaohui Qian, Jie Cui, Jian Lu, “On the origin and continuing evolution of SARS-CoV-2“, National Science Review, 03 March 2020, https://doi.org/10.1093/nsr/nwaa036

          Thus, we must be very careful when applying the “Chinese” experience elsewhere. We must work at distinguishing variables and at understanding the processes and dynamics at hand. This is nothing knew in science, as comparative approaches are, for example, detailed in John Stuart Mills’ A System of Logic (1843) with the method of agreement, of difference and combinations thereof (e.g. Encyclopaedia Britannica).

          Using a crude baseline “worst case” scenario

          We are thus faced with a lethal threat incorporating many unknowns, even after two and a half months, which, by the way, in scientific terms is an extraordinarily short time. Now, humanity has known throughout history many epidemics and pandemics, and is thus aware of the possible catastrophe a disease spreading entails. But what is meant by a possible catastrophe?

          Scientific communications and articles, as well as political ones, most of the time, shy away from giving absolute numbers.This is probably partly for fear to create a panic, out of humility because we do not really know, and out of anxiety at being later targeted as having been wrong. However, then, it becomes truly hard to understand the threat.

          To know the risks we face, to be able to better understand what could happen, what is a catastrophe, then we need to be able to get an idea of the threat one can represent. The threat must mean something. This implies having at least a crude worst case baseline scenario in terms of fatalities. In other words, we need to have an idea of what would be likely to happen if we were not acting. The aim here is not to get something precise and accurate, but to have an imperfect idea of the possible magnitude of the cost in human lives terms.

          A crude estimate of the lethal power of the COVID-19 threat

          To be able to get a crude worst case baseline scenario, we need to have first a possible figure for the number of people that could be infected, if nothing at all were done. Of course, each country and each actor is already doing a lot. Thus, as highlighted, this crude baseline worst case will explain why various authorities are fighting against the pandemic. It will indicate the magnitude of the threat and thus of the responses.

          We shall follow here epidemiologist Roy M. Anderson et al., who explains that

          “A simple calculation gives the fraction likely to be infected without mitigation. This fraction is roughly 1–1/R0.”

          Roy M Anderson, Hans Heesterbeek, Don Klinkenberg, T Déirdre Hollingsworth, “How will country-based mitigation measures influence the course of the COVID-19 epidemic?” – The Lancet – Published online March 09, 2020

          As we explained, R0 (R-nought) or basic reproduction number of an infectious disease is a measure that represents “the expected number of secondary cases produced by a typical infected individual early in an epidemic” (O Diekmann; J.A.P. Heesterbeek and J.A.J. Metz (1990). “On the definition and the computation of the basic reproduction ratio R0 in models for infectious diseases in heterogeneous populations”, Journal of Mathematical Biology 28: 356–382).

          This is most probably the calculation that is behind Chancellor Merkel’s figure for the rate of Germans the SARS-CoV-2 will probably infect (Ibid.).

          We now have a range of possibles R0 for the COVID-19. The R0 have been estimated to be between 1.6 and 3.8 (see The New Coronavirus COVID-19 Mystery – Fact-Checking). Of course, the R0 evolves with time and actions, but we are only looking for a rough estimate. Anderson et al. use a R0 = 2.6 for their crude estimate, which corresponds to 61.54%, and is within the 60% to 70% range given by Chancellor Merkel.

          Using these R0, we thus have the following worst case baseline scenarios table, for the world, with an estimated population of 7.7 billion people:

          R0 1,6

          		2,2


          		2,6


          		3,8


          % of infected population: 1–1/R0 37,50 %


          		54,54 %


          		61,54 %


          		73,68 %


          Estimated case fatality rate 0,3 % 1 % 2,2 % 3,18 % 0,3 % 1 % 2,2 % 3,18 % 0,3 % 1 % 2,2 % 3,18 % 0,3 % 1 % 2,2 % 3,18 %
          Infected population in million 2887,5 4200,0 4738,5 5673,7
          Estimated deaths in million 8,7 28,9 63,5 91,8 12,6 42,0 92,4 133,6 14,2 47,4 104,2 150,7 17,0 56,7 124,8 180,4

          Thus, at worst, considering what is known of the SARS-CoV-2 and estimated by 12 March 2020, assuming no action had been taken, we could have had to face between 8.7 and 180.4 million direct deaths worldwide.

          It is important here to stress that the estimates are for direct deaths. Indeed, if we consider the Italian tragic situation, the case-fatality rate is much higher and reached a staggering 6.7% on 12 March 2020. Pr. Ricciardi gives various possible causes for the much higher CFR in Italy, ranging from ways to establish statistics to impacts of overwhelmed hospitals on death rate ( “Coronavirus, contagiati e morti: cosa succederà in Usa, Francia e Germania. Parla Ricciardi (Oms-Salute)“). The latter notably can be seen as indirect and cascading – yet very real – causes of death. They are thus not included in the crude estimate calculated here.

          COVID-19 Worst Case Baseline Crude Estimate –
          World potential deaths if nothing had been done – The first four columns correspond to estimates for a R0 = to 1.6 thus 37.5% of the population infected. The next four to estimates for a R0 = to 2.2 thus 54.54%% of the population infected, etc. – Within each group of four columns, the first corresponds to a CFR = 0.3%, the second to a CFR = 1% then a CRF = 2,2%, and finally a CFR= 3,8%

          If we consider that the fatalities for World War II were between 70 and 85 million, then, at worst, the COVID-19 could have been more than twice as deadly.

          You can do the math for each country. For China, for example, the potential fatalities could have meant between 1.6 and 32.4 million deaths; for the U.S. between 0.4 and 7.6 million deaths.

          Assuming China has indeed completely overcome the threat and is not infected again by other countries as they become prey to the epidemic, the possible global fatalities are now lower. The baseline threat is nonetheless still there for other countries. And some risk remain also for China.

          Those figures are indeed just crude estimates, but the very high possible impact justifies the immense efforts made. It justifies that each and every person takes the pandemic seriously.

          And here, the sufferings of the 13.8% that will probably have severe disease and the 6.1% that will be in critical conditions is not taken into account (Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) – 16-24 February 2020, p.12.). If we apply the same calculation, in the case of a R0 = 2.6, thus of 61.5 % of the population being infected, this means that, without any action 653.9 million people would be at risk to suffer severely and 289 million would be in critical condition.

          The staggering difference between the rough calculation above and the reality, in China, of the detected cases – 80945 on 13 March 2020 – then fatalities – 3180 – is both a tribute to the success of the mammoth Chinese efforts (WHO report, ibid.) and a twin warning. First, the difference between real and estimated figures stresses that rough worst case estimates are nothing more than a crude evaluation of the danger faced. Second, and maybe most importantly, the difference between actual figures and estimated ones also underlines that gigantic efforts may not be an option but an imperative necessity.

          Featured image: John Hopkins CSSE: Tracking the COVID-19 (ex 2019-nCoV) spread in real-time – map for 13 March 2020 – 17:43 CET.

          A short summary FAQ

          Can we create worst case scenarios for the COVID-19 pandemic?

          Yes, definitely, we can. We can use estimates of scientific measurements to assess worst cases for the COVID-19 pandemic. This is actually necessary to know the extent of the threat, the risk and thus decide about the magnitude of the answers.

          What could be the number of deaths caused by the COVID-19?

          Worldwide, at worst, considering what is known of the SARS-CoV-2 and estimated by 12 March 2020, assuming no action had been taken, we could have had to face between 8.7 and 180.4 million direct deaths.
          This means the COVID-19 could have been more than twice as deadly as World War II.

          Why the COVID-19 is NOT a Black Swan Event

          As the COVID-19 spreads throughout the world, its cascading and multiple impacts deepen. As a result, fear spreads. Meanwhile, finance and business firms now started promoting the idea that the COVID-19 epidemic was a “black swan event”.

            For example, Goldman Sachs, in its Top of Mind, issue 86 (February 28, 2020) featured an article titled “2020’s Black Swan: coronavirus.” It is “the event that no one expected”. This, by the way, as we shall explain below is not what a black swan event is. Similarly, as the idea spreads throughout the corporate world, we read that “Sequoia Capital, one of the world’s top venture capital firms, sent a note to the founders and CEOs of its companies on Friday 6 March 2020 describing the coronavirus as “the black swan of 2020″ and urging them to brace for coming economic shocks” (Reuters 6 March 2020: Latest on the spread of coronavirus around the world).

            The only problem with characterising the COVID-19 epidemic as a black swan event is that it is untrue. At best it shows ignorance. This statement also underlines the complete incapacity or unwillingness of a large part of the corporate world, and of society more generally, to consider the future and plan ahead.

            This article explains why the COVID-19 is NOT a black swan event.

            What is a black swan event

            The idea of a “black swan event” was popularised in 2007 by Nassim Nicholas Taleb bestseller The Black Swan: the impact of the highly improbable (see Helene Lavoix, “Taleb’s Black Swans: The End of Foresight?“, The Red Team Analysis Society, 21 January 2013, and “Useful Rules for Strategic Foresight and Risk Management from Taleb’s The Black Swan“, The Red Team Analysis Society, 28 January 2013).

            Taled defines them “as unpredictable (outliers), with an extreme impact and which are, after the fact, revised as explainable and predictable”.

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            Actually, in a nutshell Taleb with The Black Swan denounces the problem and risks of induction, building upon David Hume and Karl Popper. Extremely briefly, an inductive reasoning runs as follows: all the swans observed are white, thus all swans are white… which is proven wrong when one black swan is spotted. Hence the danger of this reasoning.

            If we follow Taleb, a “black swan” is an event that cannot be foreseen because there is neither knowledge about it nor methodology to anticipate it. Black Swan events are intrinsically unknowable.

            Thus was the COVID-19 epidemic intrinsically unknowable and unpredictable?

            Did we have knowledge to foresee the COVID-19 epidemic?

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            First, we know, considering for example the SARS epidemic, that coronaviruses exist and can lead to epidemic.

            True enough the very specific strand of virus named COVID-19 was probably impossible to predict, but the emergence and spread of an epidemic of a coronavirus type was possible to foresee. Actually, such an emergence is almost certain. And the emergence of other epidemics of the same type and of other types is certain too. The problem is a problem of onset, of monitoring and then of handling of the outbreak.

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            Indeed, and second, since at least 2006, epidemiologists and serious people interested in national security and anticipation have summarised the issue for pandemics and epidemics with the catchphrase: “the question is not if but when”. They have been worried about it and they have fought to see epidemics and pandemics and their emergence and spread put on various national and global agenda. I can witness to this having worked with such a community of interest within the U.S. system.

            Finally, since at least 2000, we know that biodiversity has effects on the emergence and spread of disease (e.g. Ostfeld. and Keesing, “Biodiversity and Disease Risk: the Case of Lyme Disease“, 2000). Since then, there has been scientific debate to understand how both relate. Thus, a conservative appraisal would be that biodiversity has both positive and negative impacts on the emergence and spread of disease, according to mechanisms we still do not understand very well (e.g. Angela D. Luis, et al. “Species diversity concurrently dilutes and amplifies transmission in a zoonotic host–pathogen system through competing mechanisms“, PNAS, 2018). Biodiversity is notably operative in the spill over of infectious diseases from animals to humans (Ibid.).

            Considering the staggering rate of biodiversity loss, and our imperfect knowledge, then first this factor should have been considered. Second, the precautionary principle would have demanded that scenarios be crafted. As a result, actors would have taken into account the whole range of possibles for the future.

            Thus, we had enough knowledge to consider the possibility to see epidemics and pandemics emerge and spread at all time. Hence the current epidemic was not intrinsically unknowable. Hence it is not a black swan event.

            You may then argue that uncertainty is still part of our knowledge thus that we could not do anything to foresee the COVID-19 epidemic because of this uncertainty.

            Thus, do we have methodologies and ways that allow to handle uncertainty? Can we foresee despite uncertainty?

            Did we have methodological tools to foresee new types of epidemics

            In serious strategic foresight, strategic warning, futurism and risk management – I mean people who are seriously and systematically applying proper methodologies to anticipate – we do have ways to handle these types of possible surprises.

            Scenarios, for example, are a perfect way to handle issues presenting various types of uncertainties (e.g. Scenarios and our online course 2: Geopolitical Risks and Crisis Anticipation: Scenario building, where, by the way, a whole unit is devoted to Back Swan and Wild Card events).

            Then, we have something that is called wild card scenarios and which aim at handling difficult cases (James Dewar, “The Importance of “Wild Card” Scenarios,” Elina Hiltunen, “Was It a Wild Card or Just Our Blindness to Gradual Change?” 2006). If we assume that an epidemic has a low probability of occurence – which we can debate considering biodiversity as well as climate change, then we can at worst consider the emergence of an epidemic as a wild card. Indeed, “a wild card is a future development or event with a relatively low probability of occurrence but a likely high impact on the conduct of business,” BIPE Conseil / Copenhagen Institute for Futures Studies / Institute for the Future: Wild Cards: A Multinational Perspective, (Institute for the Future, 1992), p. v). The idea was then popularised with John L. Petersen, Out of the Blue, Wild Cards and Other Big Surprises, (The Arlington Institute, 1997, 2nd ed. Lanham: Madison Books, 1999).

            Thus we could have anticipated the COVID-19 epidemic at worst through such an approach.

            As a result, if we had enough knowledge to anticipate the emergence and spread of a new global epidemic of a coronavirus type, and if we had the methodology to anticipate such an event, furthermore considering remaining uncertainties, then the current COVID-19 epidemic is NOT a black swan event.

            The truth is that the corporate world and especially the financial world do not seriously anticipate events beyond one day, one week and at the very best three months. When they do anticipate, they are blinded by quantitative tools, as already denounced by Taleb (Ibid.). Meanwhile they think in silos. In general, despite of course exception, recruitment is done by people who have no clue about global risks and methodology to handle such risks. Recruiters privilege the wrong skills, using keywords and criteria rather than real understanding. Outside research and scientific circles, most of the time, basics of qualitative research and understanding, built over centuries, are now discarded. In most sectors, nepotism reigns. Fear of not pleasing the hierarchy or “the market” rule. Finally, there is also most probably a large part of wishful thinking and ego that stops such a successful crowd to properly and honestly consider the future.

            Thus, no, the COVID-19 epidemic is NOT a Black Swan event. Thinking so will only allow people and firms who failed to shed any responsibility for their error.

            On the other hand, is the COVID-19 epidemic a strategic surprise and a warning failure? Yes, definitely for many actors (although not for all). If we recognise this, then it will also be a way to humbly understand why part of the world was not prepared for the epidemic and why proper strategic foresight systems to anticipate it were not operational. And, so far, we are rather lucky as the case-fatality rate, although far superior to the influenza, seem to remain relatively low (see WHO and The New Coronavirus COVID-19 (ex 2019-nCoV) Mystery – Fact-Checking).

            Recognising errors and mistakes is the only way to progress. It will be the only way to do better, when the next epidemic will emerge.

            Bibliography

            BIPE Conseil / Copenhagen Institute for Futures Studies / Institute for the Future: Wild Cards: A Multinational Perspective, (Institute for the Future, 1992), p. v).

            Dewar, James A., “The Importance of “Wild Card” Scenarios,” Discussion Paper, RAND. – download pdf.

            Hiltunen, Elina, “Was It a Wild Card or Just Our Blindness to Gradual Change?” Journal of Futures Studies, Vol. 11, No. 2, November 2006, pp. 61-74

            Lavoix, Helene, “Taleb’s Black Swans: The End of Foresight?“, The Red Team Analysis Society, 21 January 2013

            Lavoix, Helene, “Useful Rules for Strategic Foresight and Risk Management from Taleb’s The Black Swan“, The Red Team Analysis Society, 28 January 2013.

            Luis, Angela D., Amy J. Kuenzi, James N. Mills. “Species diversity concurrently dilutes and amplifies transmission in a zoonotic host–pathogen system through competing mechanisms”. Proceedings of the National Academy of Sciences, 2018; 201807106 DOI: 10.1073/pnas.1807106115

            Ostfeld, R.S. and Keesing, F. (2000), Biodiversity and Disease Risk: the Case of Lyme Disease. Conservation Biology, 14: 722-728. doi:10.1046/j.1523-1739.2000.99014.x

            Petersen, John L., Out of the Blue, Wild Cards and Other Big Surprises, (The Arlington Institute, 1997, 2nd ed. Lanham: Madison Books, 1999)

            No return to the past with the COVID-19

            On 11 March, the WHO characterised the COVID-19 as a pandemic. The probability to see the WHO, finally, accepting the label had been rising everyday. Indeed, we have witnessed the proliferation of clusters and outbreaks globally, that led to the emergence of multiple epidemic centres.

            Since we first published this article, the pandemic intensified. On 28 March 2020, we shall pass 600.000 cases confirmed, for those countries who are still testing people, and for those cases that are identified. We shall also probably reach 30.000 deaths globally. The U.S. and Italy have surpassed China in numbers of cases. Italy and Europe overtook China in number of deaths. 177 countries are infected. As we expected, even though China tries to restart its economy, it cannot as the remaining part of the world faces the COVID-19.

            At the beginning of March 2020, the outbreak in China had peaked. However, by 3 March, confirmed cases had spread to more than 80 countries, by 8 March to 100 countries by 11 March to 114 countries (Andrea Shalal, Stephanie Nebehay, “WHO warns of global shortage of medical equipment to fight coronavirus“, Reuters, 3 March 2020; WHO situation report 8 March 2020, 11 March 2020).

              By 3 March, three countries faced serious epidemic clusters: Italy, Iran, and South Korea (Ibid., John Hopkins CSSE, Tracking the COVID-19 spread in real-time. Meanwhile, six countries also struggled against outbreak clusters: France, Germany, Japan, Singapore, Spain, and the United States (Ibid.). One week later, on 8 March, France Germany, the U.S. and Spain seemed to be well on their way to declare they are in a situation of epidemic (WHO update, ibid.). New clusters then touched new countries, such as the U.K., the Netherlands, Belgium etc. (Ibid.). Actually, it is the whole of Europe that is now prey to the pandemic.

              On the other hand, the epidemic outbreak seemed to slow down in one of South Korea’s cluster, which also faced a lower case-fatality rate than other countries, probably because of its extensive amount of testing (50/7134 = 0,7%).

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              The WHO was reluctant to declare a pandemic. On 2 March 2020, it reasserted its assessment according to which:

              “What we see are epidemics in different parts of the world, affecting countries in different ways and requiring a tailored response.”

              WHO Director-General’s opening remarks at the media briefing on COVID-19 – 24 February 2020

              It is only on 11 March that the word pandemic was accepted:

              “WHO has been assessing this outbreak around the clock and we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction.
              We have therefore made the assessment that COVID-19 can be characterized as a pandemic.”

              WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020

              What lies ahead is uncertain. Yet, we must prepare for it. The uncertainty and coming changes are the focus of this article and of the next ones.

              Here, we look at two major characteristics of change. First, we articulate the difference between systemic and collective changes on the one hand, specific and particular ones, on the other. We give specific examples in the case of the COVID-19, at different levels of analysis. We look at the case of the disruption of supply of personal protective equipment and at the impact of travel disruption beyond tourism. Then, at the second level of analysis, we briefly contrast potential different risks’ conditions with the examples of Monaco and Singapore.

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              With the second part, we highlight that, to envision future changes, we must first shed an implicit and false belief that assumes a return to the past will follow the COVID-19 outbreak.

              In future articles, we shall identify critical uncertainties, those that forbid a return to the past. To do so, we shall use the analytical methodology we created to help analysts in risk management. This method, “the chess analogy”, allows for identifying not only the factors and variables influencing an issue but also, and critically, their relationships and dynamics (see our online course: From Process to Creating your Analytical Model for Strategic Foresight and Warning, Early Warning, Risk Management and Scenario-building). Notably for complex issues such as epidemics and pandemics, it is impossible to continue only with old inadequate analytical models separating the world in distinct categories such as economy, health, social, political etc.

              Systemic and collective changes frame specific impacts

              The first crucial point to understand and plan ahead for changes is to distinguish and articulate between levels of analysis.

              Levels of analysis

              Indeed, the coming changes will form a larger generic framework within which particular situations will unfold. We can use the classical levels of analysis used in social sciences. In international relations, for example, following Kenneth Waltz, the first level of analysis is the individual level, the second level is the state (or polity) level and the third level is the system (Man, the State, and War: A Theoretical Analysis, 2001 [1959]).

              Here, we address the general or collective dynamics, i.e. the second and third level of analysis. Each actor will then need to assess through specific research and commissioned reports how processes located at these levels, collective and systemic, impact their particular situation. Indeed, impacts will vary wildly according to the specificities of each actor.

              One factor, different impacts at different levels

              The case of the disruption of supply of personal protective equipment

              Different impacts for different actors

              If we take the example of an economic actor, the impact of the COVID-19 multiple epidemic outbreaks depends upon the activity of the actor. For instance, the WHO warned about

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              “the severe and increasing disruption to the global supply of personal protective equipment – caused by rising demand, hoarding and misuse.”

              WHO Director-General’s opening remarks at the media briefing on COVID-19 – 3 March 2020

              This factor will negatively impact all health actors in their mission, as well as individuals seeking protection from the COVID-19. It will impact both contagion and capacity to survive the disease.

              On the other hand, the very same factor will positively impact local manufacturers of these equipments. Some small companies that may have known difficulties in facing foreign competition, for example from China, will find markets that had disappeared. Their geographical proximity and the fact they share the same experiences as their clients – indeed they are part of the same polity – will now give them a competitive advantage compared with outsourced supply. Furthermore, and to a point, the law of supply and demand will favour them. They may thus thrive for as long as the epidemic lasts. This may be enough for them to rebound.

              When impacts feed back on other levels

              Now, the accumulation of particular impacts at the first level of analysis will in turn have consequences at the collective and systemic levels.

              Fund Analysis on the COVID-19
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              For example, the rediscovery of the advantages of local production may, in the longer term, alter the systemic level, favouring and speeding the emergence of a new phase of national or local production. Meanwhile, the globalised liberal paradigm will be further adversely impacted. Various factors will condition the possibility, scope and speed of the changes at higher levels.

              The case of the disruption of person exchanges and travels: beyond tourism

              Similarly, the COVID-19 outbreak will unfavourably impact activities involving in person exchanges and travels. This is most obvious for airlines, cruise ships and long haul tourism. On the other hand, those companies that will succeed in providing a similar service while protecting their clients may develop and thrive. For example, the outbreak already benefits online activity.

              The example of tourism and related activities is obvious. However, it is important not to stop there. We should also mention as dependent upon the same factors, scientific cooperation – yet crucial for example for the development of quantum information science (see our mapping of actors in Quantum, AI, and Geopolitics (3): Mapping The Race for Quantum Computing and following articles), the famous shuttle diplomacy developed since Kissinger, and Track II diplomacy (e.g. Jeffrey Mapendere, “Track One and a Half Diplomacy and the Complementarity of Tracks“, COPOJ – Culture of Peace Online Journal, 2(1), 2000, 66-81). What, then, will be the cascading impact on diplomacy and peace. Meanwhile, international organisations and their work are also impacted. For instance, the IMF-World Bank Group 2020 spring meetings have been transformed “to a virtual format” (IMF, “Questions & Answers about the 2020 Spring Meetings“, Last Updated: March 3, 2020). This may have further consequences on the systemic level as the very actors operating at that level are directly impacted.

              Different possible fates for different polities: Monaco and Singapore

              Similarly, moving to the second level of analysis, the COVID-19 outbreak will impact different polities in different ways.

              Potential risks for Monaco?

              If we take city-states cases, we may wonder about the vulnerability to the COVID-19 of, for instance, the principality of Monaco. The current open source assessment is optimistic yet highlighting the importance of the outbreak (Amy Cartledge, “Prince Albert II responds to COVID-19 in Monaco“, Monaco Tribune, 3 March 2020). Considering Monaco’s demographics, reliance on sporting and cultural events and luxury entertainment, we may wonder about possible economic impacts should the outbreak last throughout March and beyond.

              Indeed, wealthy and very wealthy people also count people who are older and thus more likely to face the worst effects of the COVID-19, were they to be infected. For example and as indication, if we use the 2019 Forbes’ list of the The World’s Billionaires, and look at the 20 richest billionaires, we see that they are 66 years old as average, ranging from 89 to 35 years old. Fourteen of them are above 60 years old, and only four are less than fifty years old. Thus, they are more at risk to suffer from the COVID-19 than others. True enough, they may also mingle less but do they? This is only one indication, and as far as our Monegasque example is concerned, a detailed analysis would be needed. Nonetheless, this indication reveals a possible specific vulnerability.

              In any case, a country such as Monaco depends on luxury gatherings, events, wealth and security for rich but also older people (e.g. Gouvernement Princier, “Practical measures to ensure that Monaco remains a dream destination“). It may well need to develop new and specific strategies to handle the possible impacts of the COVID-19 on its fundamentals, according to various scenarios.

              Resilience for Singapore?

              By contrast, Singapore, everything being equal and despite the existence of an epidemic cluster, is most probably more resilient. Indeed, Singapore, under the leadership of then Head of Civil Servants Peter Ho embarked in whole of government changes in 2004 to overcome the threat of external events (Peter Ho, “The RAHS Story,” in Edna Tan Hong, Ngoh & Hoo Tiang Boon, ed. Thinking about the Future, Strategic anticipation and RAHS, Singapore: NSCC & RSIS, 2008, pp. xi – xix). Among these events figured the SARS epidemic (Ibid.).

              We could multiply almost ad infinitum the examples of factors created by the COVID-19 epidemic at second and third level of analysis having varying impacts at first and second level, according to specific situations.

              It is thus crucial to develop a proper framework considering collective changes that each actor will then be able to apply to its specific case.

              No return to the past

              We thus have seen examples of how changes at the second and third level of analysis may impact diversely specific actors. Now, if we want to be able to fathom these coming changes, then we must overcome a major hurdle. We must allow ourselves to think out of the box. We must overcome our cognitive straight-jackets. We must make sure we envision all possibilities. This starts with debunking the mental models that hold us prisoners.

              The myth of the return to the past

              One such currently pregnant mental model is to think the world will come back to the situation before the start of the COVID-19 outbreak.

              Most people, commentators and official actors seem indeed to believe that, at worst, a couple of days, weeks or maybe months will be difficult. Then, everything is expected to come back to normal. Rapidly, and even more so once the peak of the epidemic is past, the aim is to resume “normal production and life” (Zhou Xin, “Coronavirus: Xi Jinping sends message on China’s economy and getting back to business“, 12 February 2020).

              This is expressed through words such as “recovery”, “resumption”, “get back to normal”, “return to normal”, found in various statements and news articles’ titles (e.g. “The survey on business and economic recovery prospects… the resumption of business operations and production” in “Chinese businesses optimistic despite COVID-19 outbreak: survey” (Xinhua, 29 Feb 2020); “China wants to get back to normal as its coronavirus case numbers ease. That could be dangerous“, CNN, 28 Feb 2020; ‘A slower return to normal:’ Apple expects to miss revenue targets due to China’s coronavirus“, Fortune, 18 February 2020).

              If “normal” means a situation where the COVID-19 epidemic does not spread, then this perception may be right.

              However, if by “normal” various actors and commentators think that the world will come back to what it was before the epidemic started, then this is a wrong assumption.

              Can we apply the model of the stages of an epidemic to the world caught in an epidemic?

              The belief in a return to the past may result from a projection, on the world, of the way an epidemic unfolds.

              The stages of an epidemic model

              For example, France applies to the COVID-19 outbreak an approach by stages it developed for the 2011 influenza epidemic, as shown in the image below.

              Plan national – Pandémie grippale – 2011 – p 11 – Now applied to COVID-19

              There, each stage generates an objective and various actions (Info Coronavirus, questions fréquentes, “Quels sont les trois stades de gestion de l’épidémie de Coronavirus COVID-19 en France ?“, gouv.fr; Plan national – Pandémie grippale – 2011, pp. 10-11).

              Is Stage 4 “return to the situation ante” truly possible?

              Stage 4 corresponds, in terms of actions, to a return to the “anterior situation”. However, the actions are related to the management of the epidemic. Thus, if or when the epidemic stops then the exceptional measures taken to handle the epidemic similarly stop. As a result, one may come back to the situation ante. For example, there is no need to mobilise the same medical personal. Quarantines are not needed anymore.

              Yet, even in the medical and epidemiological field, it is likely that there will be no return to the past, stricto sensu. Indeed, human beings learn from their experience – hopefully. It is thus highly likely that the health systems, nationally and globally, will change out of the COVID-19 lessons learned. Thus, there will be no return to the past.

              An impossible return to the past: the SARS epidemic and lessons learned

              Now, if we apply the strictly epidemiological phase model to something else, then the possibility of a phase 4 that would be a return to the situation ante is even less possible.

              Let us use the case of the SARS as comparative example. With hindsight, we know that the SARS epidemic changed things for ever. For instance, as pointed out earlier, Singapore embarked on a whole of government horizon scanning and strategic foresight policy also because of the SARS epidemic (Peter Ho, Ibid.). While implementing the new policy, Singapore changed. Moreover, it also developed related international actions that impacted the world (Helene Lavoix, Actionable Foresight: The cases of Singapore and Finland, a United States Department of State Commissioned Report, 2010). As a result, the whole world changed, even if most actors did not realise it consciously or are not aware of it. And this is only one instance of change. It is however sufficient to evidence that the world after the SARS epidemic was not a coming back to the situation as it was before the SARS.

              We may also identify other candidates explaining the belief that life will resume as previously. Hope is most probably a strong explanatory factor. Interest too certainly plays a part, as those who benefited from the pre-COVID-19 epidemic system will want this system to come back. Other cognitive biases may also be at work.

              Nonetheless, despite hopes, projections and other biases, we shall never come back to the world we knew before the outbreak. In other words, everything will change.

              Thus, the nature, depth, and scope of the possible changes must be envisioned. Henceforth, we must identify the key variables that influence the existence, magnitude, speed and probability of these changes. This is what we shall do for key generic factors with future articles. Those who will be best prepared will survive best.

              Featured image: This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).

              What is Political Risk?

              Political risk is an idea many actors very often use. But what does political risk mean? What does political risk address? With the video below, we explain what is political risk.

              Meanwhile, we experiment with a new medium. We also test an approach through brief explanations of fundamental concepts and ideas. Let us know what you think.

              References and credits

              A detailed bibliography on the modern state, with the references to Max Weber and Barrington Moore Jr. can be found here.

              Concept, Design and Realisation – Dr Helene Lavoix

              Art Direction – Jean-Dominique Lavoix Carli

              Images (by order of appearance):

              Winston Churchill watching Allied vehicles crossing the Rhine – 25 mars 1945 – photograph BU 2246 from the collections of the Imperial War Museums (collection no. 4700-30) by Morris (Sgt), No 5 Army Film & Photographic Unit – CC0 / [Public Domain].

              Manif. Rouen-20-2019-01-05 by Daniel BRIOT from Rouen (France) /- CC0 / [Public Domain].

              Iceberg ©Jean-Dominique Lavoix-Carli

              Timeline evolution of life by LadyofHats – CC0 / [Public Domain].

              Pericles Gives the Funeral Speech (Perikles hält die Leichenrede), by painter Philipp von Foltz (1852) -CC0 / [Public Domain].

              King Arthur and the Knights of the Round Table, 13th century painting by Evrard d’Espinques – Original at the Bibliothèque nationale de France – CC0 / [Public Domain].

              Lhassa : palais du Potala, photo by Royonx CC0 / [Public Domain].

              Max Weber in 1894, from Wikimedia Commons, CC0 / [Public Domain].

              Barrington Moore Jr – From Wikimedia Commons “Source – http://www.news.harvard.edu/gazette/2005/10.27/11-mooreobit.html – This picture is from a Harvard newspaper, depicting sociologist Barrington Moore. It is used for educational and illustrative purpose on Wikipedia to show what he looked like. Because he is deceased, no free picture can be taken. The use of this image here would in no way harm the copyright owner’s ability to profit from the image. Therefore, the use of this image is fair use.” Likewise, we use it for educational purpose.

              Expressing and Understanding Estimative Language

              When dealing with the future, we use a language that includes specific notions such as the expression of probability and of impacts. In terms of probability, for example, we use words such as “likely” and for impacts terms such as “severe”. Furthermore, to be truly complete, we should add a confidence judgement.

              As explained by Heuer in the case of probability, these are expressions of subjective judgements. As a result, these words are a source of “ambiguity and misunderstanding” (Richards J. Jr. Heuer, , Psychology of Intelligence Analysis, Center for the Study of Intelligence, Central Intelligence Agency, 1999: 152).

              Our members and trainees can download below a “cheat sheet” of these words with their explanations. For probability we provide the correspondence between subjective words and numerical probability.

              Click on the image or link to download.
              (You need to be a member or a trainee to download the file).

              Coverpage image: Peter Lomas via Pixabay [Public Domain]

              COVID-19: Anticipation, Timing and Influence – From Mobility Restriction to Medicine Shortage

              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.

                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.

                scenario building, scenario, strategic foresight, online course, risk management, future
                Embrace Uncertainty: Anticipate, Foresee and Warn!
                Practically develop and enhance, step by step, your anticipatory analytical skills to tackle complex geopolitical, national and global security and political issues. Online course 1: from process to analytical modeling – Online course 2: scenario-building

                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.

                Too early

                When a new outbreak starts

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                Consider Coronavirus risks: commissioned reports
                Listed firms are urged to factor coronavirus risks in their financial disclosures (US SEC urged ,19 Feb; UK FRC, 18 Feb 20). All companies should consider the future likely impacts of the COVID-19 outbreak on their activity.
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                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.

                Too late

                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:
                • 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:
                • 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]

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