Preapre for the Ugly Phase

Coronavirus has been ugly enough already. Here in New York, we have 15,000 dead – we all know someone whose relative has died even if none of our own direct contacts has perished – yet. That story is being replicated around the globe.

Yet to me somehow this time has so far revealed the positive side of humanity more than the negative. True, we have the idiot in chief to make our blood boil daily, calculating when we think he deranged and deranged when we think he is calculating. True, there have been scammers, and reckless cowboys, and penny-pinching partisans and racist bigots. One lady interviewed for TV clearly thought her hair care was a human right, while other people’s health care was not.

The positive side of humanity has come through far more strongly. We have seen inspired leaders, generous philanthropists, ingenious scientists, assiduous journalists, courageous health care workers, endlessly adaptable parents, stoic shop workers and cleaners, brave patients, thoughtful neighbours and uplifting communities. Humanity delivers miracles every day, and we don’t need sightings of the Virgin Mary to prove it, we just have to keep our senses open.

My problem is that I fear for what is coming next. I predict that the balance will switch to the negative side of humanity. The positive will still be there: our hearts will be warmed by stories of miraculous recoveries and eventually by global scientific collaboration and brilliance, and a vaccine will eventually tame the beast some time in 2021.

But 2021 will feel a long time coming, and our frustrations will spill over long before then. Sitting on the couch for two months deprived of many pleasures is a manageable hardship for three months or so, especially when we remind ourselves how much tougher things are for some others. But once three months becomes six, during the stifling humidity of high summer when the city is almost unbearable in normal times, then nine, then twelve, our nerves will fray. We will stop enduring and start blaming.

Actually, I think the bigger issue will not be the continuing restrictions, but their relaxation. For it is one thing for us to be told that we are permitted to venture out, but quite another for us to be ready to do so, no matter how claustrophobic we feel at home.

Over the last few weeks, we have been led to believe that the world outside our front doors is a death trap. That has been necessary. In order to make everybody comply with the necessary precautions, we had to be cajoled into complying with many other marginally useful ones. We all took a week or more to fully embrace the restrictions, and it would have taken longer if the message had been more nuanced. Many people took far longer than a week and are still rather cavalier.

Some time soon, the message will change. People will be allowed to return to offices a few times per week under various conditions. We will be allowed back to restaurants and bars, as long as we sit far enough apart. Gyms and salons will open up, and after that other non-essential stores and businesses. We can’t stay as we are until the vaccine arrives, the balancing act between saving lives and saving livelihoods has to shift.

But will you be visiting the gym on the first day it opens? Why is something deemed reckless on one day suddenly safe the next day? The virus is not tamed. We might still die, without doing anything dumb. If we become infected, it is highly likely that most of the people we live with will be as well, including dad with his lung condition. The best that can be said is that the odds of catching the virus might be slightly less. Even that is doubtful. What might be more true is that, if we catch it, the odds of us passing it to lots of people who we don’t share a house with will be less, because of the testing and tracing. But that seems scant comfort, even if we believe it. And why should we believe it, when the president said that anybody who needed one could get a test at a time when nobody who wasn’t an NBA star could get one?

China has started opening up, and what has happened feels to me to be a good predictor of what will happen elsewhere. The restaurants are open but few are dining. The malls have reopened to silent corridors. It makes sense. It took us a week to learn how to behave to save our life. Surely it will take far longer to unlearn that?

If everybody was to take this journey in the same way at the same pace, it would be OK, the recovery would be slow but it would arrive in the end. But in reality we will all be making different trade offs, and that will create tensions between us. We will display more and more of the ugly side of humanity.

Imagine a company trying to reopen in New York, one with some small manufacturing, sales, distribution and administration. The company might or might not have received some government help, but it will still be cash poor and operationally compromised. It might have been able hurriedly to devise some safer processes and put up some screens, but it will essentially be making it up as it goes along. It will ask its staff to be part of that effort?

Many people will respond with ingenuity and humanity, but there will be conflicts as well. Some people will be in a hurry to get back to work, needing the money, while others will refuse, fearing illness. Who then gets paid? Who gets to decide? When does welfare get switched off? Can management insist, and fire those that refuse? What happens when it becomes obvious that management have designated safer conditions for themselves than their workers?

Everybody will be a part of this experiment, and everybody will have their own perspective and priorities, which will create conflicts everywhere. Already, I see vast differences when I go shopping and ride home with the heavy bags on the bus. The posher folk keep ludricrous distances from others and are wearing space suits, while the poorer people, probably still working themselves, make compromises to get on with their lives. On the affluent Q23, people won’t get on if there are more than two passengers already, but on the blue collar Q60 they fill most seats, because they have to get to work, and because at work the risks are far greater than anything on the Q60.

This will pit parent against child, husband against wife, manager against worker, worker against worker, white collar against blue collar, old against young, fit against fragile, rich against poor, business against government, government against government. The stakes are high, the rules are absent, the dimensions are vast, and the timescales are instant.

Here in the US, in the midst of all this we will have an election. Oh bliss! We all need to prepare for some ugliness in the months ahead. Hopefully we can still have our hearts warmed by the everyday stories of humanity’s kindness and ingenuity and all those other miracles. We will need them more and more as this continues. Let us pray for that vaccine, and avoid eating bleach in the meantime.

The Devil in the Denominator

At the start of my career, I was a retail sales rep. for Shell in Northern Ireland. I had to look after the Shell petrol stations in part of the province. It was a fun job.

One of the many lessons I took away from Belfast was that small businesses come in many shapes and sizes. I had a few big stations, usually on land owned by Shell, where there were several employees and even things like dedicated accountants and managers.

At the other extreme, I remember a station on a side road off a side road off a side road, operated by a charming old woman of eighty or more. My monthly sales report showed that she sold almost nothing, but she stayed open, running the place herself, alerted by a bell in her living room that was tripped if a rare customer would show up. There was no reason for her to close. She basically had no costs, and nor did we. So long as it remained safe for the Shell tanker to deliver fuel to her, the business made sense to us and it made sense to her. I called in for a social chat every six weeks or so – she always had great homemade cakes.

I often recalled this woman in later years when I was in fancy head offices devising strategies for whole countries. Senior managers always wanted key data to demonstrate that everybody understood the business that they were in charge of and to produce KPI’s that would drive strategy.

One time fairly early on I remember standing in a room with the head of the retail business for the whole UK, arguing over some set of statistics. There was much debate, because no indicator seemed stable. At one point, he shouted, exasperated, “how can we pretend to know what we are doing when we don’t even know how many sites we have?”

I immediately thought of my old lady up country in Northern Ireland. Was she still alive? Did she still sell fuel? And, even if she did, should her station actually count? The senior manager wanted to use statistics to understand his business, but every ratio seemed to involve something that he really shouldn’t care about. It shouldn’t matter to him whether my old lady was pumping gas or not, but it did, because if she stopped the national volume per site would increase.

Volume per site often became a key indicator in other contexts, with more being seen as better. I remember being told by some fancy consultant that Shell should make a bid for the Elf network, because it had the highest volume per site. The reality was that Elf had all its sites in big cities and on motorways, but that was also where price competition was fiercest and rents highest, so volume per site was only a partial guide.

There was usually a good reason to segment further. We could just look at Shell owned sites, because in those we bore most of the fixed costs and kept most of the revenue. We could exclude motorway stations because of the unique government fees they carried. But what about truckstops, with huge volumes but tiny margins? Supermarket sites? We even had some dual branded sites, for goodness sake.

I notice that most major retailers nowadays use an indicator of same store sales growth to report and analyse. I like it. It is not a ratio, but a comparison between two meaningful numbers. It strips out network changes. And it doesn’t really care about stores like that of my old lady; her volume would not influence the data much at all.

All of these thoughts of ratios and KPI’s has come to my mind recently in the context of coronavirus. Everybody is trying to publish meaningful statistics and trends, but most of them lead to more questions than answers. Usually, the reason is my old lady in Northern Ireland.

Start with the mortality rate of the disease. At the beginning this was one way the epidemiologists tried to convey the seriousness of covid 19: flu killed 0.1% of those infected, but this virus killed maybe 2%.

But the 2% figure has not really stood any exposure with reality. If you compare the ratio or deaths per cases across cities and countries, it is all over the place. Just now, in New York, we have 10,000 deaths and 100,000 confirmed cases, but nobody is claiming a mortality rate of 10%. In theory, it could be even worse, because death should be a lagging indicator.

It is obvious where the problem lies. The deaths number might be reasonably accurate, though even it has challenges, due to folk dying at home undiagnosed or dying with a range of possible causes. But the denominator, the number of cases, is even less reliable than Shell’s count of its stations.

New York has finally got its testing somewhat up to speed, but still hardly anybody is being tested. If you are an essential worker you have some chance of being tested, maybe even frequently. If you are actually admitted into hospital you will be tested. The rest of us have to sit at home and wonder. It is possible that my wife and I have both had ultra mild cases of covid, but we have no current way of knowing, and, perhaps at the end of the day it doesn’t really matter, unless there are some implications for immunity.

This problem might be called the long tail challenge or the devil in the denominator. Often, what it tells us is that we are measuring the wrong thing in the first place. For something like that, often the only way to get a good handle on infection rate would be random sampling. Even that would only work if fully recovered cases still showed up in some way. But in the end, maybe we just should not care.

As a mathematician, I have been trying to follow coronavirus statistics carefully. It has not been easy, and the dodgy denominators have not been the only reason. Perhaps reasonably, there has been some censoring going on, usually not for political reasons but to avoid spreading panic.

To his credit, Andrew Cuomo has been fairly open and fairly consistent with sharing data for New York State. Just like same store sales for a retailer, the trend of ICU admissions seems to work as a meaningful trend indicator, and the same for intubations and deaths as somewhat reliable lagging indicators.

But even these numbers are hard to compare across states and countries. Different places will have different policies for who gets admitted to hospital (do nursing homes with specialist equipment count?), and some will be more robust in their data collection. For emerging countries, even the death toll is likely to remain a colossal undercount. In the end, comparing the total death rate during the pandemic with the same time period last year will probably be the best indicator.

On balance, I think statistics help us in times like these. They can support public messaging, and eventually help our morale, once things start to head in a less horrific direction. I prefer the facts of Cuomo to the bluster of Trump: “we have sent out millions of masks”: “Nobody has told me about anybody unable to get a test”. We need data: timely, accurate, well-defined data.

The Economist, as ever, has been wonderful with its data and charts. They have been offering trend lines, with a log scale of cases or deaths plotted against the number of days since a place saw its tenth death or hundredth case: brilliant and enlightening.

But even The Economist has struggled with mortality rate, and recently it seems to have given up trying. I think that is a good move, as I remember the lessons from my old lady somewhere West of Ballymena. I remember her cakes, too.   

My main lesson so far from the crisis

As everybody scrambles for medical equipment and all of us make our own interpretation of safe social distancing protocols, there have been several attempts to discover best practice in responding to the new coronavirus.

Even though times are frantic, there have been ample opportunities. As countries, South Korea, Singapore and especially Taiwan seem to take the accolades so far. Each has advantages. They all suffered from SARS fifteen years ago and put emergency response contingencies in place. The peoples, brought up in a compliant culture, also had memories of that crisis so did not argue when asked to change habits.

All three places have managed to flatten the curve to a greater extent than models would predict, or even to have suppressed the virus completely. Testing and tracing seems to have been crucial. Mass testing, starting with anybody travelling in but extending to anybody with even slight symptoms, led to early identification of cases, and there were sufficiently few of them to make it practical to identify everybody that had been in contact with and then to test those people as well.

We all like to bash Trump over Coronavirus and there is certainly plenty of opportunity to find fault, but it was the CDC who originally screwed up, when it declined to accept the international test on offer and then ran a flawed domestic program for an alternative. That lack of testing, still existing today, made the test and trace solution completely impossible in the US.

Further, what about Europe? They had the tests available to them, but they let the virus get too far out of control to allow the winning approach to work there either. That seems like political laziness and reckless macho decision making to me.

So both Europe and the US ended up scrambling to keep people apart as the only way to try to slow the virus down. Even the UK joined in once Boris had learned how many of his citizens might be killed while he built up his herd mentality.

But which measures should be applied where, and when? Everybody rushed to keep out foreigners, but schools were left open in some places and closed in others. The list of so-called essential businesses differs greatly between US states and within Europe. Actually, in the end, t has been the people that have started to make this work. In New York, bars and restaurants can offer delivery and take-out, but demand has dipped to nearly nothing anyway, so most have closed for the duration, taking people and staff off the streets.

Among the discussion of lessons, I draw a very clear lesson that I have not read about anywhere; it is a familiar one from business. Whatever steps leaders choose to take, it is vital to manage the transition, the introduction, the implementation of those steps. Otherwise the steps risk doing more harm than good, at least for a time.

I have three clear examples of failures. The first lies at the door of Mr. Trump. Having been in denial for weeks, and spooked by the free fall in his precious stock exchange, he felt he had to make a statesmanlike address to the nation. Seemingly at the last minute, with little consultation or thought for implementation, he came up with what he thought was an easy win – stop all plane traffic in and out. He duly announced this live on TV.

The lack of planning or care for implementation was obvious for all to see. A whole series of clarifications had to be issued by officials in the hours and days that followed. No, it did not include trade. Yes, Americans could return home. And yes, there would be intensive checking at the airports and quarantine periods to follow.

Initially the stock market assumed he meant to include trade, and the sell off accelerated as a result, rough justice for Trump. Then, there came a mad rush to get the last flights back, but nobody had thought to prepare the airports, leading to lines of crowded arrival terminals stretching for hours. If only a small number had the virus when they boarded the plane to return, a lot more would have it when they escaped their arrival airport, and some of those would evade quarantine or at least spread the virus within their own families.

My second example is even more crass. Narendra Modi, having done nothing for weeks,, felt a similar statesman urge come upon him, and he literally ordered everybody home in one swoop. No essential services, no opportunity to return to a home village, no provision for people living on the streets, nothing. 

Once again, a series of clarifications and retractions followed, but the damage had been done. The panic buying unleashed in crowded places must have infected millions. Infected people rushed towards somewhere they might find a place to sit out the virus, often on foot, duly spreading the virus right around the country in one swoop.

Trump and Modi are easy targets, but my third example is closer to home, and applies to pretty well all local leaders, those people we have been praising like Andrew Cuomo here in New York. It concerns the introduction of restrictions, and their wholly predictable impact on grocery shopping. Of course there would be panic buying. And of course, the thousands of people crammed into a CostCo store would spread the virus liberally. I have witnessed strange contradictions. We won’t go within yards of each other in a park, but we were happy to take extreme risks for a few rolls of loo paper.

Of course by now it has sorted itself out. Once again the people have worked things out for themselves, and the grocery stores have got their act together, instituting one-in-one-out systems and safe checkouts and so on. But my guess is that if this had been thought of in advance, we would currently be flattening a much milder curve.

When Cuomo decided the steps were needed, the smart move would have been first to prepare with the groceries and pharmacies, working out safe protocols and allowing them to reconfigure stores and staff and supplies for a few days. It would not have been hard, and it would have saved lives.

It amazes me that this seemingly obvious lesson doesn’t seem to have been widely transferred yet. It is not too late. Other states and nations have the advantage of being weeks behind the bleeding edge, and I can only hope that they are getting help to avoid the same mistakes.

We can also use the same lesson to be smarter individually. Once a new measure comes out, we should pause, just for a few minutes, to consider carefully what it means and how we should implement it. I felt such a fool the day I wandered into the super-spreader called CostCo a couple of weeks ago, especially because it took me too long to beat a retreat. A bit of foresight would have lowered my risk profile greatly.

No doubt the poor hospitals have had similar messy learning curves, and in their case I can have more sympathy, because you can’t ask people to wait a couple of days before needing a respirator. Still, I am sure they could have done more to separate out the infectious; one smart thing that Cuomo did was to copy South Korea and get to drive-in testing locations early on.

We are still very early in this crisis, and there are many more lessons emerging. In some areas, such as the hunt for a vaccine, it is impressive to see how experts are getting things done, all over the world. In other areas we are doomed to be constrained by clueless leaders. But the lessons are not all high profile. You don’t need to be the epidemiological equivalent of a brain surgeon to work out that measured implementations save lives.