We are currently living through some interesting times, as the old Chinese saying goes.

Perhaps the scariest part in all this is not the virus, but the reactions to the virus. Trying to predict how other people will react, and how governments will react, fills us with anxiety. Will there be enough food? Or more importantly (apparently), enough toilet paper? If Coronavirus has taught us one thing, it’s that toilet paper seems to have a previously overlooked place at the base of Maslow’s hierarchy of needs.

There are lots of interesting phenomena unfolding before our eyes.

The first is the difficulty that the western democracies are having containing the virus as compared to authoritarian China, and highly socially cooperative South Korea. We westerners just seem to have taken this a lot less seriously than the South Koreans, who were never under a formal lockdown but nevertheless manage to self-isolate, “socially distance”, and test, to the extent that they appear to have managed their outbreak.

As a result, large majorities[1] in the West are now clamouring for authoritarian measures (state enforced lockdowns). Authoritarianism 1, liberalism 0. We are seeing restrictions on our liberties that most of us have never seen and would ordinarily never tolerate.

The second interesting phenomenon is the panic. This virus presents a mortal risk to vulnerable people – people with pre-existing health conditions. The reason the rest of us are being asked to self-isolate is to protect them, not ourselves. There are various estimates on what the global case fatality rate would be if we just let this thing run, as Boris Johnson attempted to do in the UK. Health services would immediately be overwhelmed, and medical workers would have to decide who lives and who dies. This is part of their job, of course, but these sorts of decisions are infrequent in well-equipped western hospitals.

If we let it run, perhaps it would be similar to the Spanish Flu pandemic – where it was estimated that 50 million people[2] died (out of a global population of around 1.8 billion in 1918). This was therefore about 2% of the global population, and that particular virus hit young people hardest.

Until recently, I suspect that most people had not heard of the Spanish flu. They did not know that it killed more people[3] than the much more well-known contemporaneous event: World War I. We should draw comfort from this – this major pandemic passed and is largely forgotten in our high school history classes. Life went on. It didn’t change the world. Today’s pandemic is changing our world, for the moment, but it too could easily pass, and be forgotten.

And yet, this has a quasi-apocalyptic feel about it – with Americans rushing out to buy automatic weapons and countries closing external (and even internal) borders. People are worried if the water and power supplies will stay on. The answer to this is: of course they will stay on. Why would they not? The chance of the average water or electricity utility worker dying from the virus is about 0.2%. Same for farmers, and truckers, and let’s not forget, toilet paper factory workers. Unless you are in the rather odd situation of having your essential services delivered to you by 85 year-old diabetics, they’re not likely to stop.

The virus will not be the end of civilization, unless we decide to end it. If we continue to treat one another civilly, everything will be fine. That’s how civilisation works.

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Let’s now get to the heart of what I want to write about – the response to the outbreak.

This is the first outbreak that has really impacted on my own freedoms and living arrangements, but it’s not the first I have experienced. Indeed, responding to them is part of my line of work as a water (and sanitation) engineer. Water-borne diseases kill around 2 million people each year[4]; routine and quiet deaths, mostly of poor children in poor countries. They often pass unnoticed in richer countries, except by charities and development agencies, and people in my line of work.

Some of these deaths occur in sporadic outbreaks of diseases like cholera, which is estimated to kill between 21,000 and 143,000 people per year[5], or Hepatitis E (est. 44,000 deaths in 2015[6]). These diseases are not respiratory, like the current Coronavirus (COVID-19), they are faecal-oral, but the basic reproductive number of cholera[7] can be similar to Coronavirus.

These are the lessons I learned from responding to Cholera and Hepatitis E outbreaks in Africa, and how they might be applied now.

1. You know what is coming, so don’t act like you don’t

When I arrived in D.R. Congo – everything was calm, and the number of cases of cholera was not unusually high. We normally had 10 per week, and the week I arrived there were 20.

However – being a geek – I entered the last three years of data from the cholera register into the computer and looked at it. I noticed that every time new cases reached 20 in a week, an outbreak followed. There was not a single event when 20 cases had not predicted an outbreak. However, our responses did not tend to start until the wards filled up, usually by week 3 or 4 of the epidemic, when cases reached 60 or 100 per week.

Now an equivalent to this is what happened when Australia hit 100 COVID-19 cases. There are no countries (that I have analysed) where 100 cases of COVID-19 did not turn into 200, and then into 500, and then into 1,000. None. And of those who reached 1,000 cases, all then went on to 10,000 (except South Korea).

So when you have 100 cases, you know you’re going to get 10,000. We should assume Australia is going to reach 10,000 cases. (In case it isn’t obvious, we are not South Korea. No one in South Korea suggested going to the footy during an epidemic).

Perhaps 5% of these will require intensive care. We typically have spare capacity of about 400 ICU beds[8].

When I saw we had 20 cases of cholera in DRC, I immediately decided we had an epidemic outbreak and started our suppression activities. It halved the case load compared to the previous outbreaks, and as a result, the new cholera treatment centre I was (simultaneously) building never filled up. Fewer people died. The flatter curve, and all that.

So – the question for our governments is: What did you do when the case load hit 100? Because at that point, 10,000 cases are more or less locked in.

2. Prepare

When faced with an exponential curve, you do not have a lot of time to formulate a policy response. On Christmas day in Congo we were told of a cholera outbreak in a nearby town. 2 people had died, and 20 cases had been identified. On the 26^th, we tried to find out if anyone was responding. The same day, we filled a Toyota Landcruiser with tools, cement, plastic sheeting, medicines, PPE, chlorine and cash.

My boss was keen for us to “assess the situation”, and perhaps do an “explo” (assessment mission to obtain more information to formulate an intervention). We simply responded “This is cholera. There is no time for that”. He let us go. On the way we met an NGO coming to do an “assessment of the situation”. By the time they had written their report, we had ended the epidemic.

I did not know exactly what we would find in this village we went to, 10 hours drive into the bush. But I did know – based on our knowledge of cholera – what we would need to do. Not everything we needed was available, for example, there was very little timber on sale. So we found a guy with a chainsaw and cut trees down. We improvised and we made stuff.

In the case of COVID-19, we already know what happed in China. We know it is a respiratory illness. We know its close relatives in the Coronavirus family very well (SARS, the common cold). We roughly know the R0 value. We know the case fatality and hospitalization rates. So, we know that protective equipment, ICU beds, oxygen and ventilators will be needed and will become a constraint on care within weeks.

I can’t emphasise this enough. We know. This future is already written.

As soon as 100 cases are hit, we needed to be buying, or failing that, making masks, ventilators, converting wards to ICU wards, and establishing new hospitals in existing buildings. We need to be buying or making COVID-19 testing kits by the hundreds of thousands. We need to ignore patents and procurement rules. This is not a speculative measure – we already know that it will be needed. Don’t wait until the wards are full.

It’s possible this preparation is underway – I hope it is[9]. But there is no excuse if it is not. This is a known known.

3. Change behaviour

Once the supply part of the problem has been addressed (preparing health care facilities for the inevitable), we need to limit the demand for them as much as possible. This is the behavioural change bit, where response times are long and impacts are uncertain. The only certainty we have to date is the efficacity of a total “Wuhan” lockdown. This is not a sustainable long-term option for any society, and so in the medium term, other approaches will be necessary.

The first communication message is probably to combat the idea that there are two types of people: the infected, and the healthy. Everyone should behave on the assumption that they are infected[10]. Assume you are death on legs, for some unlucky person.

The second is that the virus is (mostly) spread through touch and surfaces – so:

a) avoid touch, or even proximity,

b) wash your hands if you can’t avoid touching a surface or a person and

c) clean surfaces that people touch

I would not dilute the message by telling people not to touch their face. You might as well tell them not to blink. It’s a natural and unconscious movement which no-one is realistically going to stop, given they’re not even aware of it. Which means our hands will frequently be “reinfected”, if we are, and they’ll quickly infect us via our mouths if they’ve touched an infected surface or person.

So wash them before and after touching stuff.

If hands and surfaces can’t be washed frequently enough – take measures to prevent contact. This means the closure of places of close proximity and high “surface sharing” (like bars, restaurants, public transport).

Try not to be stupid

The importance of “being seen to be doing something” leads to stupid policy. Here are a few of my favourites since the start of the pandemic:

• Making announcements about upcoming restrictions which lead to mass movement before the deadline, and therefore, mass close proximity and infection. Examples are rushes on supermarkets, mass exodus from cities to rural areas prior to their isolation.
• Limiting public transport and concentrating people into fewer services
• Restricting shopping hours to 4 hours per day
• Night curfews (concentrating activity into daylight hours)
• Hundreds of thousands of people physically converging on unemployment centres because a website goes down
• Stopping salaries because people can’t work, in sectors where revenues are largely unaffected.
• State border closures when all states are already infected and in community transmission, and where the detected infection rate of citizens is about 0.02%, but letting cruise ships disembark where the detected infection rate is 5%.

Smarter policies might include:

• Keep people apart, if possible without confining them to their houses all of the time. Disperse them, e.g. open supermarkets 24 / 7 and lower prices at night. Or, if this still doesn’t thin people out, allocate people a specific time to shop e.g. based on their name, birthday, or whatever can be checked by a supermarket cashier. Offer discounts for those who respect it, or price increases for those who don’t. (A good example of using pricing was $5 for one bottle of hand sanitizer, and $95 for two).
• Clean surfaces and hands in supermarkets and other essential services all the time. Hire some of the millions of people losing their jobs to work as “sanitation workers” – spraying hands with alcohol solution on entry and exit, and wiping down every shopping trolley and doorknob in sight. If public transport is kept running, limit numbers to keep people dispersed and employ the same sanitation workers to spray hands and surfaces.
• Expand home medical visits for suspected cases – don’t get every hypochondriac to come down to the GP surgery to meet genuinely infected people.
• Follow the South Korean example of widespread, free, drive-in testing, and complete transparency of information regarding cases detected, treated, deaths, etc.
• Don’t encourage people to buy / hoard PPE (masks, etc) until all medical staff have sufficient PPE stocks for 6 months.
• Reassure people. In conjunction with producers and distributors, provide information about upstream food and basic goods production – e.g. tonnes of foods packaged / transported etc. If possible, increase production and make this widely known.  At the same time, limit purchases – perhaps using the pricing rules suggested above. Do not announce this policy in advance, make it effective immediately. Panic buying (or repeated trips to the shops to avoid quantity limitations) increase contact rather than decreasing it, but people will only panic buy if they think others will panic buy.
• Expand home delivery infrastructure – again – by hiring people who have lost their jobs.
• Safety nets: Impose a rent and mortgage repayment moratorium of three months. Roll over any short-term bank debt with central bank cash.
• Some businesses will fail due to lack of revenue and will therefore lay people off – this is unavoidable. But others (like the public sector) have revenues which are not affected, but will lay people off because they have no work to do. During the depression, Keynes advocated paying people to do pointless activities. Do this where possible. Staying at home is not pointless, after all.
• Extra measures for the vulnerable. The key people we are trying to protect are those with existing pathologies who are most at risk for COVID-19. These people need additional support to help ensure that – if they so choose – they really don’t need to leave their houses for any reason. Home deliveries etc should be prioritized for this group, and outdoor space needs to be reserved and dedicated for them for the periods they do choose to go outside for fresh air, and sunshine.

Remember, the objective of our deprivation of liberty and reduction in economic activity is not to reduce transmission to zero immediately – that won’t happen. Rather, it is to get the transmission number (R0) to below 1, so that the numbers fall back and our health services are not overwhelmed. When the number of new cases gets into the low two-digit range, perhaps a different strategy can be used (track and trace).

Some balance needs to be struck between the continuation of essential economic activity, preservation of some freedom (e.g. for a walk outside), and the protection of the vulnerable. Currently, we are fumbling our way into the single, authoritarian solution of “lockdown” largely due to a lack of faith in individual citizens to make the changes required voluntarily. Some will flout the guidelines. But the deviance of the few[11] should never be a pretext for the oppression of all. That is the original authoritarian justification.

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[1] https://www.afr.com/world/europe/brits-back-boris-on-lockdown-even-as-recession-looms-over-europe-20200325-p54dkd

[2] Figures seem to vary from 20-100 million (https://www.weforum.org/agenda/2020/03/coronavirus-great-influenza-pandemic-COVID19-prepared-outbreak/)

[3] Estimated deaths: 40 million

[4] https://www.who.int/sustainable-development/housing/health-risks/waterborne-disease/en/

[5] https://www.who.int/news-room/fact-sheets/detail/cholera

[6] https://www.who.int/news-room/fact-sheets/detail/hepatitis-e

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634708/pdf/nihms733777.pdf

[8] Assuming 80% average occupancy of Australia’s approx. 2,300 ICU beds.
https://www.abc.net.au/news/2020-03-27/coronavirus-australia-covid-19-icu-beds-ventilators-hospitals/12090420

[9] Since writing this, I read that Boris Johnson did precisely this in the UK, and Dyson expects to deliver 10,000 UK made ventilators to the British Government.

[10] Since writing this, Jacinda Arden has issued precisely this communication message.

[11] And epidemiological modelling shows us what “few” needs to look like to get a handle on the outbreak, perhaps less than 10% of the population including essential workers. https://www.abc.net.au/news/2020-03-25/coronavirus-covid-19-modelling-stay-home-chart/12084144