Category Archives: Health

Understanding global diversity in the impact of COVID-19

Having written quite extensively about the dire responses of the British government to the crises surrounding COVID-19 earlier in the year, I have held back from further criticism and writing about this for almost two months. It seems extraordinary, though, how few lessons seem to have been learnt in Europe from our experiences with COVID-19 so far, and how so many people seem to be surprised at its recent resurgence. As many of us have said for a long time, this was only to be expected, and is a direct result of the the behaviour both of individuals and also of governments. Above all, it seems to to reflect the selfish individualism, rather than communal responsibility, that has come to dominate many societies in Europe and North America in the 21st century.

The lack of research as to exactly why different countries have such varying mortality rates is also shocking (see my The influence of environmental factors on COVID-19 written in May). As a global community, very much more attention should have been given to this, so that we could by now have a better understanding of what has worked, and what has failed. Answers to these questions would enable governments now to be implementing better policies across the world to mitigate the COVID-19 related deaths that are becoming ever more numerous.

The chart below indicates the very differing numbers of deaths from COVID-19 per 100,000 population in the countries of the world that have had more than 5,000 deaths as of 21st September 2020 (data from https://coronavirus.thebaselab.com). While all such data are notoriously problematic, reported deaths from COVID-19 are more reliable than are data for case numbers (see my Data and the scandal of the UK’s COVID-19 survival rate written in April). Deaths above the usual average (excess mortality) are probably an even better measure, but are unfortunately much more difficult to obtain at a global scale. Furthermore, it must be emphasised that this sample does not include all those countries that have had far fewer deaths, and that much more research is needed in explaining why it is indeed these 25 countries that have had the most deaths in the first place.

This chart raises many unanswered questions, but does at least show two key things:

  • Some countries have “performed” very much “better” and others much “worse” than average. India, Indonesia, Germany and Pakistan appear to have performed significantly better than Peru and Belgium. Why is it, for example, that Peru has 30 times more deaths per 100,000 than does Pakistan? Yet it is extremely difficult to see what either of these groups of countries might have internally in common.
  • There nevertheless seems to be a broad group of very different countries including Sweden, Spain, the UK, Brazil, Chile, Ecuador and the USA that have so far had between 50 and 70 deaths per 100,000. Again, these countries are very diverse, be it in terms of size, demographic structure, political views, or government policies towards COVID-19, although most seem to be fairly right wing and individualistic. Interestingly Sweden with its much more relaxed policy towards social restrictions during COVID-19 appears to have done neither better nor worse than other countries in this group.

The challenge, of course, is to try to understand or explain these patterns but sadly too little research has been done on this in a systematic way to be able to draw any sound conclusions. Put simply, we do not yet really know why countries have had such diverse fortunes. Nevertheless, it is possible to begin to draw some tentative conclusions:

  • Much has been made of the environmental factors possibly influencing the spread of COVID-19, but very little actual process-based research has satisfactorily shown how viable SARS-CoV-2 actually is under a wide range of environmental conditions (see my The influence of environmental factors on Covid-19: towards a research agenda from May). The data above serves as a cautionary warning: countries with similar broad environments tend to have very differing COVID-19 trajectories. Why, for example, are Latin American countries suffering much worse than those of Africa and Asia, although they share many environmental characteritsics in common?
  • A second challenging conclusion is that the actual policies followed by governments may not be that significant in influencing the spread of COVID-19. It is thus striking that Sweden, which has followed very different policies from its neighbours, has not done significantly better or worse than them or indeed other countries such as the UK and the USA, which are widely seen to have failed in dealing with COVID-19.
  • In searching for explanations, it is also pertinent to see whether these rates could in any way be related to varying levels of inequality. However, using the Gini coefficient as a measure of inequality there seems to be no significant relationship with mortality rates (R2 = 0.027).
  • Religious beliefs and practices, likewise, do not seem to be particularly good at explaining these differenceces, although nominally Christian (or atheist) countries do fill the top 15 places in terms of mortality rates, before Iran in 16th place. Other countries with large percentages of Muslims, including Turkey, Egypt, Indonesia and Pakistan all have less than 10 deaths per 100,000. The difference between India and Pakistan (neighbours in South Asia) is particularly interesting, in that India (predominatly Hindu) has a mortality rate more than double that of Pakistan. No satisfactory explanation for this has yet been identified.
  • There has also been some speculation that individualistic societies, where people care more about themselves than they do about being responsible for their neighbours, are having higher mortality rates than do more communal societies, and in this respect the contrasts between the USA and China are indeed very marked. It is extremelt difficult to measure individualism but correlations between the Geert Hofstede Individualism (IDV) Index and mortality rates do not have a strong correlation (R2 = 0.048).

No single explanation would simply account for all of these differences. An important conclusion must therefore be that there is indeed not a single solution (apart from a vaccine or other medical interventions) that is likely to prevent dramatic increases in the prevalance of COVID-19 in these countries, and that many more deaths are therefore certain over the next six months. As individuals, we all know what can make a difference: avoid large groups, wear masks, stay outside as much as possible, wash our hands regularly, and above all act responsibility with respect to others. At all times we mut act as if we have COVID-19, and imagine how we would feel if we were the other people with whom we were interacting, and they knew that we had COVID-19. If there is any solution to COVID-19, it must be that we act responsibly rather than selfishly (see my A differentiated, responsibilities-based approach to living with the Covid-19 pandemic written in June).


The full list of countries with >5000 deaths by 21st September and therefore included in this analysis is (in descending order of deaths per 100,000) : Peru, Belgium, Spain, Brazil, Chile, Ecuador, USA, UK, Italy, Sweden, Mexico, France, Colombia, Netherlands, Argentina, Iran, South Africa, Canada, Russia, Germany, Turkey, India, Egypt, Indonesia, Pakistan

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On ageing populations, “development” and Covid-19

There is increasingly clear evidence that older people are more likely to die from Covid-19 than are younger people: on 17th February,  the China CDC weekly report showed that among the cases known in China by then, the ≥80 age group had the highest case fatality rate at 14.8% (with the 70-79 age group being 8% and the 60-69% age group being 3.6%); and in early April, the WHO Regional Director for Europe highlighted that over 95% of Covid-19 deaths occurred in those over 60, with more than 50% in those aged 80 years or older.  In the UK, the Office for National Statistics (ONS) reported in mid-April that mortality from Covid-19 increased consistently with age, with only about 13% of deaths being of people under 65.  Significantly, though it noted that men had a death rate double that of women; more recent ONS reports have also shown that (when taking into account age) Black men and women were more than four times as likely to die from Covid-19 then were those of White ethnicity, and that such differences in mortality were partly a result of socio-economic disadvantage.  These data are stark, and are as yet still not fully explained.  As people grow older, they generally have greater comorbidities, and it may be the impact that Covid-19 has on these other health problems that is more significant than age itself.

However, this is an important reminder that Covid-19 is primarily an old-people’s disease.  It is striking to recall that in 1951 life expectancy at birth in England and Wales was only 66.4 for men and 71.5 for women; in 1901 the figures were 48.5 and 52.4 respectively (ONS, 2015).  Put simply, people born 70 years ago were not expected to live to the age at which most people are now dying from Covid-19.  This has important ramifications, and raises very difficult questions.  Have people, perhaps, become over expectant about longevity?  Will Covid-19 temper our aspirations to live for ever?  Will it be a check on the ambitions of companies such as Novartis, Alphabet and Illumina to extend life well beyond 100 years (CNBC, 2019)?  Is the main problem of Covid-19 that most people living in the richer countires of the world have become too cosy in their expectations of living to a ripe old age?

Implications for Europe and north America: too many old people

Thought experiments can be a helpful means of highlighting challenging issues.  Suppose, for example, that there had been no lockdowns in Europe and North America.  It seems very likely that substantial numbers of elderly people would have died already (see projections by epidemiologists at Imperial College which suggested that without mitigation strategies Covid-19 would have resulted in 40 milllion deaths globally in 2020).  If a vaccine or cure is not found, then it still seems likely that large numbers of elderly people will indeed die in Europe at an age well short of what they and their families have grown accustomed to expecting.

However, think of the impact that this will have on the economy and health services.  Once large numbers of elderly people have died, national pension bills will fall, the burden on health services will be reduced, the percentage of people within the economically productive age range will increase, and the economic vitality of their countries will be revitalised.  If Covid-19 (or its successors) become an everyday part of life, the economic “burden” of older people will be dramatically reduced.  It is scarcely surprising that rumours  circulated about the intentions of UK government policy in early- to mid-March.  As Martin Shaw noted at the time, it had been credibly reported that the “Government’s strategy was ‘herd immunity, protect the economy and if that means that some pensioners die, too bad’; or as summed up even more succinctly by a senior Tory, ‘Herd immunity and let the old people die’”.  Whilst the government strenuosly denied this, there is a realistic logic to the idea that letting large numbers of old people die would have clear economic benefits, and would avoid the very considerable costs that are accruing as a result of economic shutdown.

I should stress that this is definitely not a scenario that I would want to encourage or endorse, but in the early part of May, the balance of popular opinion (or the influence of the business community and mainstream media in the UK) does seem to be swinging towards a view that the costs of lockdown are too high to continue to protect the elderly, especially in those countries where there have already been very high death rates (as in Belgium, the UK, France, Italy, Spain and the USA).  Yet, the 20th and latest Imperial College Covid-19 report  concludes for Italy that “even a 20% return to pre-lockdown mobility could lead to a resurgence in the number of deaths far greater than experienced in the current wave in several regions”.

Implications for Africa and South Asia: youthful countries

The real purpose of this reflection, though, is to consider the implications of the above arguments for some of the economically poorest countries in the world.  Data about Covid-19 infections and deaths in Africa and Asia are likely to be even less reliable than they are in Europe, and the countries in these continents are in any case much earlier in their encounters with Covid-19 than are those of Europe.  Recent reports, for example, suggest that the real number of deaths related to Covid-19 may be many times the number that are currently reported (see The Guardian‘s recent report on Somalia).  Nevertheless, we do have relatively accurate data about the demographic structures of most countries in the world.  The chart below therefore shows the relationships between current density of Covid-19 deaths and the percentage of population aged ≥65 for a sample of countries.[i]

Screenshot 2020-05-08 at 08.33.35

This graph is striking, but difficut to interpret (and can be misleading), mainly because most countries in Africa and Latin America are only at an early stage in their Covid-19 outbreaks.  We simply do not know how many deaths they are likely to witness, and few models have yet been published that predict the likely outcomes.   However, with the very notable exceptions of Japan, Greece and Germany, it re-emphasises that high percentages of Covid-19 deaths are mainly found in those countries that have more than 15% of their populations aged ≥65.  Even Brazil, where the death rate is currently growing rapidly, is still nowhere near at the level of mortality that has occurred in Europe and the USA.  The quite remarkable achievement of Greece, with only 147 deaths by 7th May, is also highly noteworthy because despite a fragile health service and an elderly population it has managed to achieve something that most other European countries have been unable to do.  Most commentators suggest that this is mainly because it imposed a dramatic lockdown even before the first deaths were recorded.

Most countries of the world have intiated lockdowns, and these are having particularly significant impacts on the poorest and most marginalised who can least afford it. An obvious question therefore arises: if Covid-19 mainly affects the elderly, should countries with young populations (such as most of those of Africa, Asia and Latin America) follow the “older” countries in imposing strict lockdowns that will have damaging effects on their economies and the livelihoods of those who can least afford it?  Put another way, are the mitigating actions of European and North American countries, where more than 15% of their populations are ≥65, relevant to economically poorer countries with less than 10% of their populations in this age group?

It is far from easy to answer this.  Perhaps the very small numbers of people reportedly dying in Africa at present is only because the coronavirus has not yet gained a grip, and any loosening of the mitigating measures would unleash the pandemic at a scale similar to that seen in Europe.  The WHO, for example, has warned  that the Covid-19 pandemic might kill as many as 190,000 people in Africa in the year ahead (Al Jazeera, 8th May), with many more dying subsequently.  This may well be true, but there is at least a chance that the youthful populations of Africa will be better able to deal with Covid-19 than have done the older populations of Europe.  It must, though, be emphasised that many younger people who are infected with Covid-19 do indeed have serious illnesses, and some die.  We also do not yet know the long-term health impacts of this coronavirus.  Moreover, the evidence that socially disadvantaged people are also more likely to die than their more affluent neighbours further suggests that the poorest and most marginalised in these countries may well have higher death rates.

As I have illustrated elsewhere, there is some (but by no means conclusive) evidence that environmental factors may also play a role in limiting the spread of Covid-19.  If the environments of Africa and South Asia are indeed not particularly conducive to the spread of Covid-19, then their youthful populations might not need to endure the very tight lockdowns imposed in many European countries. That having been said, the rapidly increasing number of infections and deaths in Brazil (with 121,600 cases and 8,022 deaths as of 7th May), which has physical environments and climates similar to many parts of western and southern Africa, does not bode well for the future spread of Covid-19 in Africa.

Conclusions

In conclusion, there remains much that is unknown about how Covid-19 spreads and who it affects most damagingly.  The evidence from Japan, Greece and Germany shows that even when countries do have a high percentage of elderly people, it is still possible to contain and limit the spread of Covid-19, thereby preventing very large numbers of deaths.  The abject failures of governments in countries such as the UK and Belgium to manage the pandemic and save lives likewise indicate how not to respond to the pandemic.  The governments of African and South Asian countries, with their youthful populations who appear less likely to suffer severe symptoms, may well therefore have an advantage over their European counterparts.  If they can draw lessons about what has worked and what has failed, then they are also in a good position to bounce back swiftly from the economic harm caused by economic and social lockdowns.

 


[i] The selected countries included the ten most populous countries in the world (in descending order of total population, China, India, USA, Indonesia, Pakistan, Brazil, Nigeria, Bangladesh, Russia, Mexico), a selection of European countries with mixed trajectories (listed alphabetically, Belgium, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, Switzerland), and a diverse sample of African (alphabetically, DRC, Egypt, Kenya, Rwanda, South Africa, Tanzania), and other (alphabetically, Iran, Japan, South Korea, Turkey) countries.

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Face masks and Covid-19: communal not individual relevance

face-masks-coronavirus-china-afpOne of the starkest differences between East Asian and European/North American responses to the Covid-19 pandemic has been in their differing attitudes towards face masks (used here generically, and differentiated from FFP3, also known as N95, respirators) : they are common in East Asian countries such as China, South Korea, Singapore and Japan, and yet are rarely to be seen in other parts of the world.  They have been part of the package of solutions recommended in East Asia, where infection and mortality rates have generally been quite low; yet they are absent in Europe and North America where rates are much higher.

World Health Organisation advice, followed assiduously by European governments and the U.S. Centers for Disease Control and Prevention (CDC) is clear:

  • If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.
  • Wear a mask if you are coughing or sneezing.
  • Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water.
  • If you wear a mask, then you must know how to use it and dispose of it properly.

This is frequently interepreted in an abbreviated form, as by the BBC, to imply that “Only two types of people should wear masks: those who are sick and show symptoms, and those who are caring for people who are suspected to have the coronavirus”.

The case against wearing face masks comes down essentially to the argument that they will do little to protect someone from getting infected.  This is fundamentally an individualistic argument: “If I wear a mask it won’t be much good to me”.  However, from a communal perspective that is absolutely not the point; what matters is that if you wear a mask and are unknowingly infected it may help to prevent you spreading the infection to many other people.  Wearing a mask is about others not yourself.

A growing body of evidence is now suggesting that masks can indeed help to slow the spread of Covid-19:

  • The markedly different histories of infection between countries where masks are encouraged/enforced as part of a package of measures, and those where they are discouraged, is forcing researchers and policy makers to try to explain why.  Masks are an obvious possible answer.
  • It is increasingly being suggested that many Covid-19 carriers are asymptomatic.  They therefore don’t know that they might infect people, and so are going about their daily lives doing just that.  If they had been wearing masks, it is argued, this could reduce the number of people that they infect.
  • Dentists and healthcare workers in many parts of the world are encouraged or required to use masks both to provide some protection from patients, but also to protect patients from any infections that a dentist may have.  If such masks are seen to be offering patients some protection, then it seems strange to suggest that they offer no protection against a coronavirus such as Covid-19 (see reviews of surgical masks and N95 masks by Loeb et al., 2009, and more recently by Long et al., 2020)
  • Chinese doctors and scientists are increasingly confident that masks do make a difference.  In a recent interview, George Gao (Head of the Chinese Center for Disease Control and Prevention) has thus suggested that “The big mistake in the U.S. and Europe, in my opinion, is that people aren’t wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role—you’ve got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others”.

In societies such as the USA and much of Europe where the focus tends to be more on the “self” rather than the “community” it is scarcely surprising that individuals and their politicians see little value in masks; but in more communal societies, where there is  perhaps more care for others, then masks are seen as an important part of the armour against Covid-19.

Many governments fear that encouraging citizens to wear face masks would mean that there would be insufficient left for medical professionals to wear.   This, however, is rather a lame excuse.  Such governments could readily have put in place systems in early February to prepare to expand production of protective clothing.  It is not too late for them urgently to do so.  The BBC thus reports that “UK clothes makers say the government has wasted time in ordering personal protective equipment for NHS staff.  Fashion and textile firms believe they could have begun making gowns and masks for front-line workers 10 days ago”.

However, for those who do care about their neighbours and don’t want to disrupt the official production of masks for healthcare providers, an increasing amount of guidance is now available for making your own masks, as at:

These are clearly not going to be as good as masks made by companies to stringent regulatory standards (for UK see Regulatory status of equipment being used to help prevent coronavirus (COVID-19)), but they may well offer at least some protection to reduce the communal spread of Covid-19.  Pressure on demand is likely to become very much worse than it is at present, especially when imported masks are low in supply and often fail to satisfy these standards: recent reports (see for example Business Insider, 29th March) thus suggest that 600,000 masks imported from China have had to be recalled by the Dutch government because they are faulty.  In countries unable even to import masks from elsewhere, domestic production in line with international standards (see Wong, A. and Wilkinson, A., 2020) can be recommended.

Above all, the discussion should not so much be about “will I be protected?” but instead “how can I protect others?“.  It rather depends on what kind of society we wish to live in – especially for those who are left after this pandemic has run its course.

[Update 30th March – it is great to see that Austria has announced today, the day after I wrote the above, that it is to make wearing masks compulsory, and will distribute basic masks for free at the entrances to all supermarkets]

[Update 31st March – Tom Whipple in The Times notes comments from Prof Cheng at Birmingham University and Prof Cowling at University of Hong Kong in favour of wearing masks, although Prof McNally, also from Birmingham, expressed concern that this would be counterproductive since people would think they could still go out]

[Update 2nd April – David Shukman on the BBC News site: Coronavirus: Expert panel to assess face mask use by public.  The WHO should have acted much more quickly on changing its advice]

[Update 7th April – Link to Lydia Bourouiba’s important study on turbulent gas clouds and respiratory pathogen emission: coughs and sneezes can spread #Covid19 7-8 m; CDC guidance is only 2 m; masks might help https://jamanetwork.com/journals/jama/fullarticle/2763852. We really need to rethink social distancing…]

[Update 7th JulyBBC Coronavirus: Don’t leave home without a face covering, says science body – why has it taken so long for people in the UK to argue vociferously for this?]

[Update 15th DecemberScientists say masks could stop coronavirus spreading in busy streets – nothing much has changed, apart from many thousands having died unnecessarily!  Just goes to show what an individualistic and selfish society we live in – as many of us have said for months, masks can help protect other people.  Every life saved matters]

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Donor and government funding of Covid-19 digital initiatives

Masai children 2We are all going to be affected by Covid-19, and we must work together across the world if we are going to come out of the next year peacefully and coherently.  The world in a year’s time will be fundamentally different from how it is now; now is the time to start planning for that future. The countries that will be most adversely affected by Covid-19 are not the rich and powerful, but those that are the weakest and that have the least developed healthcare systems.  Across the world, many well-intentioned people are struggling to do what they can to make a difference in the short-term, but many of these initiatives will fail; most of them are duplicating ongoing activity elsewhere; many of them will do more harm than good.

This is a plea for us all to learn from our past mistakes, and work collaboratively in the interests of the world’s poorest and most marginalised rather than competitively and selfishly for ourselves.

Past mistakes

Bilateral donors and international organisations are always eager to use their resources at times of crisis both to try to do good, but also to be seen to be trying to do good.  Companies and civil society organisations also often try to use such crises to generate revenue and raise their own profiles.  As a result many crises tend to benefit the companies and NGOs more than they do the purportedly intended beneficiaries.

This was classically, and sadly, demonstrated in the Ebola outbreak in West Africa in 2014, especially with the funding of numerous Internet-based initiatives – at a time when only a small fraction of the population in the infected countries was actually connected to the Internet.  At that time, I wrote a short piece that highlighted the many initiatives ongoing in the continent.  Amongst other things this noted that:

  • “A real challenge now, though, is that so many initiatives are trying to develop digital resources to support the response to Ebola that there is a danger of massive duplication of effort, overlap, and simply overload on the already stretched infrastructure, and indeed people, in the affected countries”, and
  • “Many, many poor people will die of Ebola before we get it under control collectively. We must never make the same mistakes again”.

I have not subsequently found any rigorous monitoring and evaluation reports about the efficacy of most of the initiatives that I then listed, nor of the countless other digital technology projects that were funded and implemented at the time.  However, many such projects hadn’t produced anything of value before the crisis ended, and most failed to many any significant impact on mortality rates or on the lives of those people affected.

In the hope of trying not to make these same mistakes again, might I suggest the following short-term and longer-term things to bear in mind as we seek to reduce the deaths and disruption caused by Covid-19.

Short-term responses

The following five short-term issues strike me as being particularly important for governments and donors to bear in mind, especially in the context of the use of digital technologies:

  • Support and use existing technologies.  In most (but not all) instances the development and production of new technological solutions will take longer than the immediate outbreak that they are designed to respond to.  Only fund initiatives that will still be relevant after the immediate crisis is over, or that will enable better responses to be made to similar crises in the future.  Support solutions that are already proven to work.
  • Co-ordinate and collaborate rather than compete. Countless initiatives are being developed to try to resolves certain aspects of the Covid-19 crisis, such as lack of ventilators or the development of effective testing kits (see below).  This is often because of factors such as national pride and the competitive advantage that many companies (and NGOs) are seeking to achieve.  As a result, there is wasteful duplication of effort, insufficient sharing of good practice, and the poor and marginalised usually do not receive the optimal treatment.  It is essential for international organisations to share widely accepted good practices and technological designs that can be used across the world in the interests of the least powerful.
  • Ensure that what you fund does more good than harm.  Many initiatives are rushed onto the market without having been sufficiently tried and tested in clinical contexts.  Already, we have seen a plethora of false information being published about Covid-19, some out of ignorance and some deliberate falsification.  It is essential that governments and donors support reliable initiatives, and that possible unintended consequences are thorouighly considered.
  • Remember that science is a contested field.  Value-free science does not exisit.  Scientists are generally as interested in their own careers as anyone else.  There is also little universal scientific agreement on anything.  Hence, it is important for politicians and decision makers carefully to evaluate different ideas and proposed solutions, and never to resort to claiming that they are acting on scientific advice.  If you are a leader you have to make some tough decisions.
  • Ensure that funding goes to where it is most needed.  In many such crises funding that is made available is inappropriately used, and it is therefore essential for governments and donors to put in place effective and robus measures to ensure transparency and probity in funding.  A recent letter from Transparency International to the US Congress, for example, recommends 25 anti-corruption measures that it believes are necessary to ” help protect against self-interested parties taking advantage of this emergency for their own benefit and thereby undermining the safety of our communities”.

In the medium term…

Immediate action on Covid-19 is urgent, but a well thought-through and rigorous medium-term response by governments and donors is even more important, especially in the context of the use of digital technologies:

  • We must start planning now for what the world will be like in 18 months time.  Two things about Covid-19 are certain: many people will die, and it will change the world forever.  Already it is clear that one outcome will be vastly greater global use  of digital technologies.  This, for example, is likely dramatically to change the ways in which people shop: as they get used to buying more of their requirements online, traditional suppliers will have to adapt their practices very much more rapipdly than they have been able to do to date.  Those with access to digital technologies will become even more advantaged compared with those who cannot afford them, do not know how to use them, or do not have access to them.
  • Planning for fundamental changes to infrastructure and government services: education and health.  The impact of Covid-19 on the provision of basic government services is likely to be dramatic, and particularly so in countries with weak infrastructures and limited provision of fundamental services.  Large numbers of teachers, doctors and nurses are likely to die across the world, and we need to find ways to help ensure that education and health services can be not only restored but also revitalised.  Indeed, we should see this as an opportunity to introduce new and better systems to enable people to live healthier and more fulfilled lives.  The development of carefully thought through recommendations on these issues, involving widespread representative consultation, in the months ahead will be very important if governments, especially in the poorest countries, are to be able to make wise use of the opportunities that Covid-19 is creating.  There is a very significant role for all donors in supporting such initiatives.
  • Communities, collaboration and co-operation.  Covid-19 offers an opportunity for fundamentally different types of economy and society to be shaped.  New forms of communal activity are already emerging in countries that have been hardest hit by Covid-19.  Already, there are numerous reports of the dramatic impact of self-isolation and reduction of transport pollution on air quality and weather in different parts of the world (see The Independent, NPR, CarbonBrief).  Challenges with obtaining food and other resources are also forcing many people to lead more frugal lives.  However, those who wish to see more communal and collaborative social formations in the future will need to work hard to ensure that the individualistic, profit-oriented, greedy and selfish societies in which we live today do not become ever more entrenched.  We need to grasp this opportunity together to help build a better future, especially in the interests of the poor and marginalised.

Examples of wasteful duplication of effort

Already a plethora of wasteful (in terms of both time and money), competitive and duplicative initiatives to tackle various aspects of the Covid-19 pandemic have been set in motion.  These reflect not only commercial interests, but also national pride – and in some instances quite blatant racism. Many are also very ambitious, planning to deliver products in only a few weeks.  Of course critical care ventilators, test kits, vaccines and ways of identifying antibodies are incredibly important, but greater global collaboration and sharing would help to guarantee both quantity and quality of recommended solutions.  International Organisations have a key role to play in establishing appropriate standards for such resources, and for sharing Open Source (or other forms of communal) templates and designs.  Just a very few of the vast number of ongoing initiatives are given in the reports below:

Critical care ventilators

Testing kits

Despite criticisms of the replicative and wasteful nature of many such initiatives, there are a few initiatives at a global scale that do offer hope.  Prime among these must be Jack Ma’s donation of 20,000 testing kits to each of 54 African countries, which will go some way to reducing the need for these to be domestically produced across the continent.  But this is sadly only a small shower of rain on an otherwise parched continent.  Working together, we have much more to be achieved, both now and in the months ahead.

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Crowdsourcing Covid-19 infection rates

Covid-19, 19 March 2020, Source: https://coronavirus.thebaselab.com/

Covid-19, 19 March 2020, Source: https://coronavirus.thebaselab.com/

I have become increasingly frustrated by the continued global reporting of highly misleading figures for the number of Covid-19 infections in different countries.  Such “official” figures are collected in very different ways by governments and can therefore not simply be compared with each other.  Moreover, when they are used to calculate death rates they become much more problematic.  At the very least, everyone who cites such figures should refer to them as “Officially reported Infections”

As I write (19th March 2020, 17.10 UK time), the otherwise excellent thebaselab‘s documentation of the coronavirus’s evolution and spread gives mortality rates (based on deaths as a percentage of infected cases) for China as 4.01%, Italy as 8.34% and the UK as 5.09%.  However, as countries are being overwhelmed by Covid-19, most no longer have the capacity to test all those who fear that they might be infected.  Hence, as the numbers of tests as a percentage of total cases go down, the death rates will appear to go up.  It is fortunately widely suggested that most people who become infected with Covid-19 will only have a mild illness (and they are not being tested in most countries), but the numbers of deaths become staggering if these mortality rates are extrapolated.  Even if only 50% of people are infected (UK estimates are currently between 60% and 80% – see the Imperial College Report of 16th March that estimates that 81% of the UK and US populations will be infected), and such mortality rates are used, the figures (at present rates) become frightening:

  • In Italy, with a total population of 60.48 m, this would mean that 30.24 m people would be infected, which with a mortality rate of 8.34% would imply that 2.52 m people would die;
  • In the UK, with a total population of 66.34 m, this would mean that 33.17 m people would be infected, which with a mortality rate of 5.09% would imply that 1.69 m people would die.

These figures are unrealistic, because only a fraction of the total number of infected people are being tested, and so the reported infection rates are much lower than in reality.  In order to stop such speculations, and to reduce widespread panic, it is essential that all reporting of “Infected Cases” is therefore clarified, or preferably stopped.  Nevertheless, the most likely impact of Covid-19 is still much greater than most people realise or can fully appreciate.  The Imperial College Report (p.16) thus suggests that even if all patients were to be treated, there would still be around 250,000 deaths in Great Britain and 1.1-1.2 m in the USA; doing nothing, means that more than half a million people might die in the UK.

Having accurate data on infection rates is essential for effective policy making and disease management.  Globally, there are simply not enough testing kits or expertise to be able to get even an approximately accurate figure for real infections rates.  Hence, many surrogate measures have been used, all of which have to make complex assumptions about the sample populations from which they are drawn.  An alternative that is fortunately beginning to be considered is the use of digital technologies and social media.  Whilst by no means everyone has access to digital technologies or Internet connectivity, very large samples can be generated.  It is estimated that on average 2.26 billion people use one of the Facebook family of services every day; 30% of the world’s population is a large sample.  Existing crowdsourcing and social media platforms could therefore be used to provide valuable data that might help improve the modelling, and thus the management of this pandemic.

Crowdsourcing

[Great to see that since I first wrote this, Liquid Telecom has used Ushahidi to develop a crowd sourced Covid-19 data gathering initiative]

The violence in Kenya following the disputed Presidential elections in 2007, provided the cradle for the development of the Open Source crowdmapping platform, Ushahidi, which has subsequently been used in responding to disasters such as the earthquakes in Haiti and Nepal, and valuable lessons have been learnt from these experiences.  While there are many challenges in using such technologies, the announcement on 18th March that Ushahidi is waiving its Basic Plan fees for 90 days is very much to be welcomed, and provides an excellent opportunity to use such technologies better to understand (and therefore hopefully help to control) the spread of Covid-19.  However, there is a huge danger that such an opportunity may be missed.

The following (at a bare minimum) would seem to be necessary to maximise the opportunity for such crowdsourcing to be successful:

  • We must act urgently. The failure of countries across the world to act in January, once the likely impact of events in Wuhan unravelled was staggering. If we are to do anything, we have to act now, not least to help protect the poorest countries in the world with the weakest medical services.  Waiting even a fortnight will be too late.
  • Some kind of co-ordination and sharing of good practices is necessary. Whilst a global initiative might be feasible, it would seem more practicable for national initiatives to be created, led and inspired by local activists.  However, for data to be comparable (thereby enabling better modelling to take place) it is crucial for these national initiatives to co-operate and use similar methods and approaches.  There must also be close collaboration with the leading researchers in global infectious disease analysis to identify what the most meaningful indicators might be, as well as international organisations such as the WHO to help disseminate practical findings..
  • An agreed classification. For this to be effective there needs to be a simple agreed classification that people across the world could easily enter into a platform.  Perhaps something along these lines might be appropriate: #CovidS (I think I might have symptoms), #Covid7 (I have had symptoms for 7 days), #Covid14 (I have had symptoms for 14 days), #CovidT (I have been tested and I have it), #Covid0 (I have been tested and I don’t have it), #CovidH (I have been hospitalised), #CovidX (a person has died from it).
  • Practical dissemination.  Were such a platform (or national platforms) to be created, there would need to be widespread publicity, preferably by governments and mobile operators, to encourage as many people as possible to enter their information.  Mutiple languages would need to be incorporated, and the interfaces would have to be as appealing and simple as possible so as to encourage maximum submission of information.

Ushahidi as a platform is particularly appealing, since it enables people to submit information in multiple ways, not only using the internet (such as e-mail and Twitter), but also through SMS messages.  These data can then readily be displayed spatially in real time, so that planners and modellers can see the visual spread of the coronavirus.  There are certainly problems with such an approach, not least concerning how many people would use it and thus how large a sample would be generated, but it is definitely something that we should be exploring collectively further.

Social media

An alternative approach that is hopefully also already being explored by global corporations (but I have not yet read of any such definite projects underway) could be the use of existing social media platforms, such as Facebook/WhatsApp, WeChat or Twitter to collate information about people’s infection with Covid-19. Indeed, I hope that these major corporations have already been exploring innovative and beneficial uses to which their technologies could be put.  However, if this if going to be of any real practical use we must act very quickly.

In essence, all that would be needed would be for there to be an agreed global classification of hashtags (as tentatively suggested above), and then a very widespread marketing programme to encourage everyone who uses these platforms simply to post their status, and any subsequent changes.  The data would need to be released to those undertaking the modelling, and carefully curated information shared with the public.

Whilst such suggestions are not intended to replace existing methods of estimating the spread of infectious diseases, they could provide a valuable additional source of data that could enable modelling to be more accurate.  Not only could this reduce the number of deaths from Covid-19, but it could also help reassure the billions of people who will live through the pandemic.  Of course, such methods also have their sampling challenges, and the data would still need to be carefully interpreted, but this could indeed be a worthwhile initiative that would not be particularly difficult or expensive to initiate if global corporations had the will to do so.

Some final reflections

Already there are numerous new initiatives being set up across the world to find ways through which the latest digital technologies might be used in efforts to minimise the impact of Covid-19. The usual suspects are already there as headlines such as these attest: Blockchain Cures COVID-19 Related Issues in China, AI vs. Coronavirus: How artificial intelligence is now helping in the fight against COVID-19, or Using the Internet of Things To Fight Virus Outbreaks. While some of these may have potential in the future when the next pandemic strikes, it is unlikely that they will have much significant impact  on Covid-19.  If we are going to do anything about it, we must act now with existing well known, easy to use, and reliable digital technologies.

I fear that this will not happen.  I fear that we will see numerous companies and civil society organisations approaching donors with brilliant new innovative “solutions” that will require much funding and will take a year to implement.  By then it will be too late, and they will be forgotten and out of date by the time the next pandemic arrives.  Donors should resist the temptation to fund these.  We need to learn from what happened in West Africa with the spread of Ebola in 2014, when more than 200 digital initiatives seeking to provide information relating to the virus were initiated and funded (see my post On the contribution of ICTs to overcoming the impact of Ebola).  Most (although not all) failed to make any significant impact on the lives and deaths of those affected, and the only people who really benefitted were the companies and the staff working in the civil society organisations who proposed the “innovations”.

This is just a plea for those of us interested in these things to work together collaboratively, collectively and quickly to use what technologies we have at our fingertips to begin to make an impact.  Next week it will probably be too late…

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