What if the facts can't help us?
April 19th, 2020
In a complex environment, the future is uncertain and unpredictable. And this is difficult to accept. We like to listen to experts who confidently tell us what past events mean and how the future will unfold. There are many examples of television programs, radio broadcasts and newspaper items in which experts in various fields tell coherent stories based on apparently logical connections. Think, for example, of experts who at the end of the day, tell how the stock market behaved, what the underlying causes of that behavior were and how this will develop in the near future.
If we assume that we can say something meaningful about future events in a complex environment, it is more sensible to rely on algorithms than expert guidance. Over the past decades, numerous studies have shown that experts are unsuccessful in predicting the future. Although the best algorithms only provide low to moderate validity, they still score better than experts. If the validity of an algorithm has been established, even if it is a low validity, it makes sense to use it when making decisions. A low degree of validity is better than no validity at all. However, it is important to ensure that we always expect less from the algorithm than the low validity we can expect. Worryingly, many people, including policy advisors and top level managers, still believe it is possible to make accurate predictions. Despite overwhelming evidence that this is impossible.
Of all events, rare or unusual events, these are events that lie outside the realm of regular expectations, are the most difficult to predict. Statistically, there is too little data available to make reliable calculations. In a complex environment, an infinite number of coherent scenarios can be created based on the limited amount of available data points. Besides the fact that these events are very difficult to predict, we also find it more difficult to imagine these events. So we have to prepare for the fact that the next rare event will not really be what we have in mind. A possible example of a rare or unusual event in our recent past is the outbreak of the Covid-19 virus. At this moment, the outbreak is relatively young and we’re still focused on controlling the spread of the virus. However, it will not be long before more questions will be asked whether we could have expected the virus outbreak and whether we have taken the right measures at the rights time.
Before you read on I would like to ask you two questions.
- Has China taken adequate measures to address the Covid-19 virus?
- Has the Netherlands taken adequate measures to address the Covid-19 virus?
First, let’s take a look at recent history and see if we can identify some connections.
In October 2019, the Lancet published an article describing a discussion within the scientific community about the need to spend more money, effort and global policy on animal-human infectious diseases. Different approaches are being discussed to improve people’s preparedness for new viruses (1). The Global Virome Project is a project with the aim of creating an atlas that contains all viruses that could pose a threat to humans (2). It is estimated that there are between 631.000 and 827.000 unknown viruses that have the potential to infect humans. Building an atlas should ensure that we are warned for future threats, prevent and mitigate future threats, and get input for a more sophisticated approach in the event of an unexpected virus outbreak. Other researchers are studying viruses that have spilled over from animals to humans. These are diseases such as influenza, Ebola, AIDS and MERS. Some viruses, have caused many human deaths because the virus did not cause symptoms in animals. In other cases, we were simply insufficiently prepared and not vigilant enough. MERS, a virus found in camels in Saudi Arabia, spilled over to humans in 2013. This resulted in a serious outbreak across half of the world(1). A decade earlier, the SARS virus spilled over from animals, possibly the civet cat, to humans. This virus infected 8.096 people in 26 countries with 774 deaths as a result. The first infections occurred in the Chinese province of Guangdong (3). Several countries are starting to participate in the Global Virome Project. China and Thailand are the first countries to collect animal samples. And China will lead the project. The head of the Chinese Center for Disease Control and Prevention, Goa Fu, says “we all know there are almost certainly new viruses that could cause the next global pandemic. Ideally we can develop vaccines and a diagnoses for such viruses even before they cause human epidemics”(4).
Two months after the publication of the Lancet article, rumor is that a new virus has started to spread in China. Medical doctors in Wuhan begin to detect cases of unexplainable pneumonia as of December 21st, 2019 (5). Li Wenliang, a physician from the Hubei Province in China who died of the Covid-19 virus on February 14th, sends a message via WeChat to some fellow physicians on December 30th. He warns his colleagues of a possible virus outbreak that is very similar to SARS and advises them to protect themselves against infection. A few days after sending this message, Li Wenliang has to report to the Public Security Bureau in Wuhan to sign a statemen accusing him of making false allegations and disturbing public order (6). On December 31st, China alerts the World Health Organization (WHO) that it has established an unusual respiratory condition in several people. Most of the affected people work at a seafood market. In its statement, China says that there is no evidence that the virus can be transmitted from one person to another (7). Following this initial warning, the WHO announces on January 8th that Chinese researches have determined that it regards a new virus that belongs to the family of the Corona virus. There is no evidence that the virus is transmissible from human to human (8). On January 10th, Li Wenliang falls ill. His symptoms start with coughing and fever. Two days later he is admitted to the hospital (9). As of January 13th, the governments of Thailand, Japan, South Korea, Vietnam, Taiwan, the United States, Hong Kong, and Singapore report that the virus has been detected in their country. At this moment, according to the official reports, there is one known death. The WHO reports on January 14th, that investigations by the Chinese government have not found clear evidence that the virus is transmissible from human to human (10). On January 19th, China reports that the new Corona virus is still preventable and controllable. China reports that 60 confirmed cases of the new virus are known and two people have died from the virus. Eventually, the head of China’s National Health Commission reports on January 20th, that the virus can be transmitted from person to person. According to the report, two cases have been identified in which the virus has been transmitted from person to person (11,12). Doubts about the truthfulness of the Chinese government’s reporting regarding the real nature and spread of the virus keep growing. On January 23th, a news item states that the Wuhan police has not only charged Li Wenliang, on January 3th, for publishing and spreading false information on the internet without checking the facts, but eight people in total. Police have posted information about the arrests on social media channels and they warn Wuhan residents to obey the law and not to spread false information (13). In addition, a study published in the Lancet shows that physicians indeed had strong evidence that the virus was transmitted from human to human (14). In the meantime, according to official reports, 200 registered infections have been reported in China on January 23th, and three people have died from the virus. Although there are, according to official reports, only two known cases of human to human transmission of the virus, and the total number of official deaths can be counted on one hand, the cities of Wuhan, Xiantoa and Chibi have shut down all air and train traffic at that time. The next day, images of a construction site where dozens of excavators work to construct a temporary emergency hospital are shown all over the world.
That same week, China imposed a lockdown on 56 million people. According to the WHO, there is no global public health emergency. In a speech on January 23th, the Director General of the WHO states that there is an emergency in China. However, it is not a global emergency. It can become a global emergency. There is no evidence of human to human transmission of the virus outside of China. This has occurred within China but it seems to be limited to family groups and health care workers. China has taken measures to limit the spread of the virus in Wuhan and other cities. The WHO hopes that these measures will be effective and won’t last too long. Additional measures to further limit travel or trade are at this moment not considered necessary by the WHO (15).
Before I continue, I would like to ask you the same two questions that I’ve asked you before again. 1. Has China taken adequate measures to address the Covid-19 virus? 2. Has the Netherlands taken adequate measures to address the Covid-19 virus?
Following a news item by the NOS at January 20th, reporting that China has announced that the virus has transmitted from human to human (12), Bruno Bruins, the former Minister of Medical Care, writes his first letter about the Covid-19 virus to the House of Representatives (16). In this letter, Bruins states that his strategy is based on information from the WHO, the European Center for Disease Prevention and Control (ECDC) and the Chinese government. Bruins writes that according to the ECDC, the chance that the virus will come to Europe is small. Two days later, France announces that the Covid-19 virus has been detected in three people.
Let’s make a make a jump in time. On January 7th, the WHO reports that there is a major disruption in the market for personal protective equipment. Demand is 100 times higher than normal and prices are 20 times higher than normal. The WHO appreciates that organizations only provide masks to medical professionals. Medical professionals have 1st priority and people who are ill or care for someone who is ill have 2nd priority (17). Since most registered infections are still in China at this moment, the demand for protective equipment is also largest in China. De Volkskrant reports on April 11th, that on February 10th, the Netherlands provided humanitarian aid to China in the form of masks, gloves, overalls, and other medical equipment. The shipment of goods, which were sent from China to the Netherlands in October 2019, to China is at the request of the Chinese ambassador to the Netherlands, Xu Hong (18). One day later, the NOS reports that 1000 people have died from Covid-19. At this moment, there are over 42.000 reported infections in China and 319 in 24 other countries (19). In the Netherlands, spring holidays are about to start. Around this time of year many people go on winter sports and carnival is about to start. This is the moment when the spread of the Covid-19 virus through Europe, and eventually the Netherlands, takes off. On February 23th, there are 152 identified infections in Italy and the first infection in the Netherlands is reported on February 27th (20). At this moment, Dutch experts are still optimistic about the ability of the Netherlands to control the virus. Menno de Jong, virologist of the Amsterdam UMC says to the Parool on January 29th, “the threat of infectious diseases is no less than before. The big difference is that virus control has also gone global. You can attribute the increase of medical knowledge to globalization too. That makes infectious disease more manageable than in the past”. De Jong also says, “preparations take place in peacetime, as we call virus free periods. The army is also building barracks in peacetime, we do something similar. In the next phase, you mobilize troops. Now that the virus is in the Netherlands, you can attack. For example, by quarantining infected people and screening the people, they’ve been in contact with, for corona. In global history, 2020 is the best year to fight infectious diseases. Certainly in a country like the Netherlands”(21). In the same article, Arie van der Ende, molecular microbiologist at the Amsterdam UMC, says “there is great alertness. For good reasons, but thanks to the dense infrastructure in the Netherlands, I am convinced that we can limit the number of infections”(21). Hans van Vliet, of the RIVM says “Corona is now appearing in so many places in the world that it is difficult to get it under control. That chance is shrinking every day. However, I think we are not standing on the eve of a major epidemic in the Netherlands. Our vigilance and previous preparations will prevent this”(21).
With the knowledge we have today, it is incredibly difficult to imagine how it is possible that the many decisive moments I described above, unfold the way they did. And this is just a random and small selection of all the decisions that have been taken. From a human right perspective, many questions can be asked about the way the Chinese government acted in response to the virus outbreak, but this is a subject for another time.
I suggest that we now first focus on the first question that I’ve asked.
- Has China taken adequate measures to address the Covid-19 virus?
The animal-human infectious disease domain, which includes virus outbreaks, is a complex domain. This means that it is impossible to make reliable predictions about the future. A characteristic of complex environments is that low impact events are very likely. High impact events are less common but are plausible. The reason why I use the term plausible is because events with a high impact are more likely in a complex environment than we usually think. Since we can be almost certain that events, that have an impact, will happen, we can investigate whether and to what extent our systems are vulnerable for an impact. The first and foremost elements, belonging to this system, that come to mind, are animals, humans and viruses. Over the last hundred years, the human population has grown from one billion to seven billion. Therefore, it is not surprising that research by the EcoHealth Alliance has shown that virus spillovers from animals to humans have increased with a factor two to three compared to 40 years ago (22). Since land use is the largest predictor of virus spillovers, this number will continue to grow as long as the population of humans continues to grow. After all, with the growth of our population, we are using more and more land. For example, for livestock farming (23). Researchers estimate that there are currently roughly between 631.000 and 827.000 unknown viruses that have the potential to spill over from animals to humans (1). Based on this information, we can easily infer that we are vulnerable to virus outbreaks. As Goa Fu said in 2018 “we all know there are almost certainly new viruses that could cause the next global pandemic”(4).
The Covid-19 virus outbreak is an event with a major impact. However, the outbreak lies within the realm of regular expectations regarding virus outbreaks. So it is not an unexpected or rare event. The event is comparable to the many events with a small impact that have a higher level of occurrence. The only difference is that is has a bigger impact. It was known in advance that the chance of an event with a major impact in this complex domain was plausible. Scientists had warned governments about this for years. However, the timing and severity of the outbreak could not be predicted in advance. Even when the first signals of the outbreak were revealed, it was not yet possible to predict the severity of the outbreak. Here we make the transition from predicting future events to dealing with problems in a complex environment. Just as we cannot predict future events in a complex environment, we cannot predict the development of events. Unfortunately, today’s problem is not necessarily tomorrow’s problem.
So how about the Netherlands?
2. Has the Netherlands taken adequate measures to address the Covid-19 virus?
In the Netherlands, decision makers involved in the approach of the Covid-19 virus outbreak have been guided by experts in the virus domain. As already mentioned, research has shown that experts are not successful in predicting future events. Since the virus was able to develop in China, and other countries, a relatively long time before it reached the Netherlands, it was no longer about predicting the event but about predicting the development of the problem and handling the problem. One possible reason why experts are not successful in predicting high impact events in complex domains, is because they focus on the normal situation. Signals activate known existing patterns (24). This is not effective since unexpected events often have a different appearance than more regular events. In a complex environment, the challenge, when making decisions, is that there is a high degree of uncertainty and that information is always missing. Although in this case, the outbreak has a relatively similar appearance compared to outbreaks with a small impact, the involved decision makers have clearly had a hard time with this. In the approach of the Covid-19 virus outbreak, a fact based reactive approach was chosen. This approach was justified by the message from experts that the Netherlands, with its strong health system and good infrastructure, would be perfectly capable of limiting the number of infections and controlling the virus. If we had faced one of the many events with a low impact, these expectations would have been right. Only when the facts have proven that the current event has a big impact, experts start to adjust their reporting. On March 31st, NRC writes “we were mistaken about it” says a microbiologist, “about how incredibly easily the virus spreads. Our detection network was not up to that”(20).
So far, we have mainly looked at the past. But what will happen next? Will we keep following a fact based reactive approach? As mentioned, in a complex environment today’s problem is not necessarily tomorrow’s problem. What do the experts actually say about how this virus outbreak will proceed? A complex environment requires a flexible and curious policy based on the expectation that changes will happen and new events, with small or big impacts, will occur. In addition, a complex environment requires decision makers who are willing to make decisions based on limited and incomplete information. There are other domains where decision makers are used to make decisions with limited information, sometimes even intelligence or minor indications instead of evidence. Think, for example, of the intelligence domain. What can we learn from the mistakes made in this domains?
In our complex global society, groups of people worldwide are strongly connected. Viruses spread through mutual contact. Due to the unknown characteristics of the Covid-19 virus, many characteristics are still unknown, it was not possible to implement specific measures to limit the spread of the virus. Therefore, it was necessary to implement broad freedom restricting measures to reduce the spread of the virus. The future cannot be predicted, but the current situation can be measured and monitored. What are the current characteristics of the virus we are currently facing? With characteristics I mean, for example, how is the virus transmitted, how many people carry the virus (or have carried the virus) that don’t show symptoms, how has the virus spread so far, etcetera. At present, the broad freedom restricting measures are still in place in many countries. By better understanding the virus, more specific measures can be taken to limit the spread of this specific virus. The limited information about the current characteristics of the virus make it unclear which measures could be effective, and force us to keep the comprehensive and restrictive measures in place.
Covid-19, with its current characteristics is highly contagious and causes deaths. The current measures prevent an irreversible disaster. If we reduce the current measures, and try to restrict the spread of the virus with more specific and tailor made measures, we must expect changes and new events. Furthermore, it is clear that future virus outbreaks are inevitable. Therefore, politicians, and other people in charge in this domain, will need to implement flexible and curious policies, and will have to become adept at making decisions with limited information in highly uncertain situations.
- The Lancet, Do we need a Global Virome Project
- Science, The Global Virome Project.
- History, SARS Pandemic: How the Virus Spread Around the World in 2003.
- ChinaDaily, China to help ID unknown lethal viruses.
- CCDC weekly, A Novel Coronavirus Genome Identified in a Cluster of Pneumonia Cases.
- The Lancet, Li Wenliang.
- World Health Organization, Pneumonia of unknown cause – China.
- Stat, WHO says mysterious illness in China is likely being caused by new virus.
- BBC, Li Wenliang: Coronavirus kills Chinese whistleblower doctor.
- Twitter, WHO no evidence human-to-human transmission.
- ABC News, Human-to-human transmission of new coronavirus reported in China.
- NOS, Nieuwe Wuhan-virus overdraagbaar van mens op mens.
- Poynter, China arrested 8 for spreading ‘hoaxes’ about what is now known as coronavirus. What happened to them?
- A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission.
- World Health Organization, WHO Director-General’s statement on the advice of the IHR Emergency Committee on Novel Coronavirus.
- Rijksoverheid, Kamerstukken 22-1-2020.
- Republic world, WHO Announces ‘severe’ Disruption In Global Supply Of Masks and Medical Equipment
- de Volkskrant, Nederland stuurde in februari ondanks WHO-waarschuwing miljoenen medische hulpmiddelen naar China.
- NOS, Duizendste corona-dode: ‘Kans steeds kleiner dat virus vanzelf verdwijnt
- Het virus kwam sneller dan de overheid reageerde.
- Het Parool, De kans op een epidemie is klein in Nederland.
- EcoHealth Alliance.
- Nautilus, The man who saw the pandemic coming.
- Camerer, Colin F., and Eric J. Johnson. “The process-performance paradox in expert judgment: How can experts know so much and predict so badly.” Research on judgment and decision making: Currents, connections, and controversies 342 (1997).