Disease and Incompetence

It is a truth universally acknowledged, that a nation, in the throes of a dire predicament, must be in want of a competent government.

To be honest, that truth is not universally acknowledged. It is particularly the case that the wanton incompetence of some governments in the face of the COVID pandemic has many wondering about the role of government at all. So, let’s look at what we know so far about how competence, or its lack, has affected outcomes. 

Why think of this in the context of a “new normal”? Because the pandemic is not going away, but what we demand and expect from governments should be shaped by what is essential in the context of existential threats from disease and other challenges. COVID shows what governments can and should do in our immediate futures.

Where you live can kill you

In a nutshell: how well a government led the response to COVID has, so far, an effect on mortality of at least 2,000 fold. Meaning: in one reasonably affluent country, the death rate is 0.3 / million, while in another of comparable size it’s nearly 800. A cluster of countries have kept their death tolls in single digits / million; another cluster has death tolls from 100 to 600. It’s amazing.

The lessons, perhaps simplified: preparedness; rapid response; respect for the numbers and the science; leading the people to join in sharing the mutual sacrifice for the mutual benefit. Do these well, and your country and your economy gets through this. Do these poorly, and a vast death toll and economic devastation are the consequences.

A rapid response

The need for early, fast and firm response is driven by the inexorable maths of exponential growth. Consider: COVID’s early spread in many countries had the number of infected individuals rising at 25% per day. That’s just insane growth. At that rate, in just 31 days the number of infected individuals rises 1,000-fold. (To be precise: 1.25^31 = 1,009.) A country that postpones action for a month faces a 1,000-fold larger challenge. 

Thus, the vast range: Taiwan, like some other countries, had a pandemic preparedness plan and started acting to it even before they had confirmed cases. Unlike some others, it stuck to it. It enforced compliance – but had a populace already used to the arrival of contagions from China. It had medical expertise in the country’s leadership – including an epidemiologist as the number 2 in the whole country.

Comparing COVID mortality to date with wealth and population. 

Data from Our World in Data (COVID mortality as of 19th May, 2020, .csv files), IMF / Wikipedia for GDP/capita (nominal) and population data. The three countries indicated by colors are discussed further in this piece. Circles are proportional to population.

Some notes:

  • The 19 countries whose outcomes (so far) are depicted here are all Western-style economies with democratic governments and a generally free press. They have roughly similar economies.
  • Three countries (USA, UK and Australia) have bombastic, populist leaders. One has done well in fighting COVID; the other two have not. Australia’s death rate is about 1% of those in the USA or the UK – and nobody can describe Australians as normally meek and compliant.
  • The country with the weakest government institutions – Belgium (which didn’t even have a functioning government from 2007 to 2011) currently has the worst COVID outcomes.
  • A particular and stunning peculiarity: NONE of the Asia-Pacific countries have more than 6 deaths per million – but this cannot be attributed to Confucian compliance with central leadership since Australia and New Zealand are in this list. In contrast, NONE of the Atlantic / Mediterranean countries have less than 30 deaths per million.

What do we want from leaders? What do we want from government?

Do we want a self-proclaimed superman as leader? “I alone can fix it” (Donald Trump, Republican convention, 2016). Do we want leaders who aim to unify us and create strength from cohesion? “trust your values — our values — and to hold me responsible for living up to them” (Ronald Reagan, Republican convention, 1980, cited in the same article). Do we want Government to be the first place to solve problems for the people (what Britain’s Tories sneered at as a ‘Nanny State’)?

And then comes a super-national-scale crisis, and the criteria for government come into sharp focus.

As the COVID pandemic slowly resolves, it will eventually be a task for historians and pundits to analyze which government approaches worked, and which did not. It’s definitely early to make definitive conclusions, but it’s not too early to look across the various countries’ (and USA states’) responses and note some that seem to have worked so far, and some that seem utterly disastrous, to date. Let’s assume that “worked” and “disastrous” can be quantified by counting COVID death rates (COVID-caused deaths per million people).

If you scan the data, and reject those with dodgy data (I don’t believe Mexico’s or China’s data or those from lots of countries) you still end up with death rates that vary by factors greater than 2,000. Literally: your chance of dying was better or worse by vast factors depending quite narrowly on WHERE you live. The weirdness of this defies easy explanation.

The large ranges continue within countries and within regions: I live in Northern California which has far lower COVID contagion rates than the Los Angeles and San Diego regions.

It’s hard – impossible for now – to peel out unambiguous causes. But let’s look at a few countries, each under democratic governments, of similar sizes (geographic and population), with a vigorous, caustic free press, each relatively wealthy and reasonably literate, and with comparable and generally adequate access to inexpensive health care: Italy, Taiwan, Britain.

Italy – a country on fire with COVID

Italy’s prior experience with plagues and epidemics is well-known, since its role in the 13th to 18th centuries included much worldwide trade: the word “quarantine” derives from the Venetian dialect expression of 40 days – the time ships were supposed to be isolated before they offloaded crew and cargo.

Italy’s high death toll from COVID, what caused it? Was it …  a/ the high percentage of the population that was elderly? (nearly 95% of the deaths were of people aged 60 or older, and Italy has the 5th-highest median age of any country), b/ dense housing in older buildings with inadequate ventilation or sanitation? c/ vigorous community activities (can you imagine Italy without noisy cafes, markets or churches)? d/ multiple generations living together? e/ a communication style that tolerates proximity – cheek kissing – and noisy speaking? f/ smoking? g/ other diseases, comorbidities? h/ inadequate health care prior to or during COVID? I’ve probably missed a few, but even so: the likelihood of getting clear causality against these is slim. (Note, all the data on Italy are from the Wikipedia entry, HERE.)

A brief calendar of COVID in Italy

  • First cases emerged in late January via travellers from Wuhan (who had arrived on 23rd January)
  • First clusters emerged from mid- to 21st February
  • Lockdown started in specific towns from 22nd February and expanded nationwide around 8th March (nearly three weeks after clusters were identified): one month from cases arriving.
  • Case confirmation peak occurs around March 20th
  • Peak deaths around March 27th.

The chart below depicts the growth and tapering off of COVID in Italy.

Growth of COVID in Italy from the discovery of the first COVID clusters

If there’s one unambiguous lesson from Italy, it’s this: the two-plus week between identifying clusters and initiating widespread lockdown cost dearly in terms of deaths.

Taiwan gets COVID nearly right

Taiwan’s experience with Chinese-origin epidemics is recent and urgent. The SARS epidemic in 2004 found the country ill-prepared and with its representation at the World Health Organization shut off by the People’s Republic of China. This led Taiwan to bolster its epidemic response. By late 2019, it had a robust Center for Disease Control, modelled explicitly on the similarly-named USA institute, with a health command center explicitly set up to deal with epidemics. They’d planned for this for years, and knew they’d be on their own. Further, it had as the nation’s vice president an individual – Chen Chien-Jen – with a master’s degree in public health (and some years in medical practice, still focusing on pandemic response). Taiwan does have free and universal health care, but ⅔ of beds in Taiwan are in privately-operated facilities, with many or most services paid for through the central government.

But, proximity to China and the enormous, fluid flow of people across the Taiwan strait still left it vulnerable. As many as  850,000 of its citizens reside on the mainland; another 400,000 work there and rotate between work on the mainland and home in Taiwan. For work and for tourism, China send many visitors to Taiwan – 2.71 million last year. Add to these factors very dense housing, some old and with poor sanitation, extensive use of public transport, and a tradition of communal eating in the evenings. (see discussion of Taiwan’s predicament and response HERE)

IT wasn’t all bad. People throughout Taiwan would have seen Wuhan not as some strange, distant locale, but as a place where family members originated or worked. They knew of the potential of chimeric contagion from China. Many would have heard family word-of-mouth news, in addition to the TV or newspaper reports. They knew. (The data below are, again, from Wikipedia, link HERE.)

A brief calendar of COVID in Taiwan

  • Starting at the end of December, travellers arriving from Wuhan were subject to health tests upon arrival and contact tracing thereafter. (Note: they started acting BEFORE there were known cases in country!)
  • Taiwan’s first case emerged in late January via a traveller from Wuhan (who had arrived on 21st January)
  • Throughout January over 100 discrete measures were implemented, including a vast increase in production and distribution of masks (and mandatory mask-wearing) and of alcohol for hand sanitizers. The government invoked emergency measures to step up production of protective gear. Mask production reached 10 million per day in mid-March (at which point it started exporting them; some are sold, but many are donated to countries suffering worse from COVID, including the USA). By 20th January, Taiwan had on hand 44 million surgical masks, 1.9 million N95 masks and 1,100 negative-pressure isolation rooms. The existential threat from COVID meant political barriers and industry rivalries were, for the moment, set aside.
  • By 14th March, persons arriving in Taiwan had to go into 14-day quarantine.
  • Various measures including shuttering restaurants and businesses took effect.
  • The peak of new cases occurred around 20th March (even so, just 27 cases were reported on that day). There isn’t really a peak in deaths, because there were so few. As of this writing, only seven COVID deaths have occurred in Taiwan (an island with a population of just under 24 million).

By mid-May, Taiwan’s industry had largely retooled for safe return-to-work. (One large firm, well-known for its role in producing famous computers, took a few days to retool a factory to make protective equipment – for its own workers.) Mandatory face masks, temperature testing, contact tracing, and so on are everywhere. One recent informal estimate I’ve seen is that Taiwan’s economy, which was projected to have 2% growth this year before COVID hit, may still eke out moderate growth for calendar 2020.

UK gets COVID nearly completely wrong

It’s hard to imagine a country getting so much wrong about a pandemic. The UK had a highly educated population, broad access to a well-liked (but financially stressed) health care system, a world-leading set of universities and pharmaceutical companies. Even the World Health Organization relied for much of its epidemiological analysis on a UK group (the MRC Centre for Global Infectious Disease Analysis at Imperial College: this writer’s alma mater, although at a different time, and I know none of the participants). And yet …

It now seems that the first COVID cases in the UK may have occurred as early as late November. More certainly, several members of a choir returned from Wuhan in mid-December with COVID-19 symptoms. But, even as late as 22nd January, when the medical world was fully informed of the outbreak in Wuhan, the outbreak’s severity was only upgraded from “very low” to “low”. It was too late, as there were other cases and clusters, and travel bans were ineffective, as people continued to flow in from other countries in Asia and from Europe. People coming into the UK from known-affected countries throughout Asia and Europe were politely asked to self-isolate – if they already had symptoms. Again, we see a country that acted – gently – against COVID months after it was already spread out of control.

In mid-March, the Imperial College epidemiology group published a report (report 9) – which had already been shared with UK and USA leaders – predicting that significant non-pharmaceutical interventions were needed, else the death toll would reach a half million in the UK (and as many as 2.2 million in the USA).  Despite this the prime minister, throughout much of March, while steadily activating some of the machinery of the health system, was out in public, shaking hands with all he could. Through the middle of March, he took part in the debates and ceremonies at the Houses of Parliament – a grand but crowded and poorly ventilated place, with all members obliged to sit close to each other. The prime minister’s jaunty continuous handshakes caught up with him: he was hospitalized with COVID – including a few scary days in ICU.

On the same day as the Imperial report 9 was published, the British government “suggested” people should avoid pubs and clubs and theaters. Their enforced closing followed a week later. And, a few weeks later yet, it created a series of military field hospitals “Nightingales” (named for the 19th century pioneer of field medicine for the British Army, Florence Nightingale) – that took over exhibition halls and warehouses and aircraft hangars; they shut down airports to dedicate them only to medical flights. The government appealed for the public to volunteer to provide food and essential services to those shut in, or to provide childcare support for medical staffs and so on. They sought 200,000 volunteers and got over a million.

All that was so much, and so well coordinated. But all so late, in the face of unconstrained exponential growth. And such dissonance between the explicit capabilities of government and the ‘no problem’ leadership message expressed by the personal behaviors of Johnson and others.

Disclaimers: I’m British by birth, and have a PhD, in physics, from Imperial College, but have no contact with the Imperial epidemiology team. I’ve lived in Taiwan – and have at least once met both the current premier, Tsai Ing-Wen, and her predecessor, Ma Ing-Jou – but we don’t know each other. I am a US citizen and resident, but elected to not discuss the USA because there are no nations of comparable size and complexity to use as peers. I have no financial interests or conflicts to disclose.

A version of this document with more complete data source information is online at THIS LINK. That document may be updated as new COVID data become available.

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One thought on “Disease and Incompetence

  1. Thank you for this post. It would be interesting to hear your take on Governor Cuomo’s handling of the crisis in NYS. One statistic that perplexes me is the vast difference in confirmed cases between Iran and Iraq, countries which share a very long border. I wonder whether the population pyramids – which have very different shapes – could be part of the explanation.

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