The Total War of Pandemic

It took us a little time to figure out how to fit the Coronavirus pandemic into a fully formed political debate. We’ve hit our stride pretty quickly though. It turns out it actually fits neatly into the same sort of debate we’ve always had in American politics.

Coastal elites with their charts and mathematical models and high science degrees are telling everyone else that there’s a giant problem. And while most of them have the sorts of jobs where they make a living in just about any economy, they’ve gone ahead and forced us to do something that’s killed all the higher paying working-class jobs. And they’re hiding behind a “phony” motivation of protecting the most vulnerable Americans in order to do it.

Meanwhile, Joe the plumber, just doesn’t get it. The universe is trying to tell him the world is going to end. And he doesn’t care. All he cares about is himself and people that look like him. All the experts agree but he doesn’t care because he doesn’t understand science. It may be hard on him. But it’s not as hard on him as it is on the truly poor and the elderly. Who are ALL going to die. Why won’t he just listen and do what we tell him to?

Healthcare, globalization, immigration, climate change…now Covid-19.

It’s on.

There’s one critical difference here though. This is not a hypothetical slow burn discussion that requires pundits and politicians to pour gas on it from time to time to keep it going. It’s an acute crisis that will force an outcome, one way or another, in weeks or months…not years or decades.

Over 4,000 Americans have died in the last 24 hours. Most of the deaths are in metropolitan areas like New York. Meanwhile, we’ve got at least 25% unemployment in Michigan. And they’re not alone.

Neither of these issues are sustainable for very long. So, we’ve got some extremely difficult choices that are going to require thinking that can’t be contained by the standard 21st Century American political debate.

It starts by acknowledging that both the problems of a sustained great depression level economic crash and an overwhelming viral pandemic killing thousands of Americans a day are things we can’t live with. We don’t need hyperbolic claims that recessions kill people. And we don’t need people who are urging us to open the economy being called murderers. It’s sufficient to simply say that we can’t trade one outcome for the other. Not for long.

Debates over what’s worse aren’t necessary. Clearly the pandemic is worse because it’s killing thousands of people a day. But it’s worse the way dying of dehydration is worse than starving to death. You can tell people not to eat or they’ll die of thirst for only so long before they go looking for food on their own. The protests are already starting.

Objectively we should all agree that there will be a time when we can start to have an intelligent discussion about when the economic impact begins to outweigh the value of future improvements in public safety. For those folks in the “break a few eggs to make an omelet” camp that think we’re there now, I’ve got a chart originally published by The New Atlantis that can add perspective:

 

Covid

Dr. Phil was right when he went on Fox News and said we don’t close down the economy for car crashes or the flu, both of which kill tens of thousands of Americans a year. As you can see from the chart, Covid-19 is not the flu or car crashes. Or anything we’ve seen since the advent of modern medicine. That curve will flatten out on it’s own at some point…probably… But we’d kill a whole lot of people to find out when. We’ll definately break some eggs. It’s not clear whether or not we’d even have an omelet on the other side though. Which brings up the most critical aspect of our current predicament.

While the Covid-19 weekly death curve looks like that, does it really matter if someone declares the economy open?

Let’s take my hometown of Atlantic City as a case study for this question. It’s a single industry town of casino tourism. Right now all casinos are closed. If Governor Phil Murphy declared the economy “open” at noon today, are people going to the Casino this weekend? Are Americans going to gather in the thousands in small rooms and close seating with senior citizens to gamble?

How about you? Are you going to a crowded restaurant? To the movies? Are you getting on a plane to fly cross country for a work conference you don’t feel like going to?

How about employers? Are they making their staff show up?

Right now over four thousand Cops in New York City have Covid-19. 27 have died. That’s more police officers than died on 9/11. And about 10% of all line of duty related deaths for NYC cops since 1950. In three weeks. You read that right.

Whose excited to bring their teams back together…?

The painful reality is that in many areas, the government hasn’t shut down the economy. The virus has. And for the others, the belief is that it would just be a matter of time before it does so we may as well save lives while we wait it out.

That’s the right strategy. It’s just not complete.

“Stay the fuck home” memes are a fun way to value signal that you’re on team coastal elite. But they don’t do much to help people who don’t know what they’re going to do if we shut down forever. The good news for them is that no one thinks we can shut down forever. The bad news is that no one has provided an alternative reality to look forward to. Which means people are arguing what they know; “open” or “shut”. The future looks like neither, at least not for a little while. So a political debate is not only unhelpful, it’s fundamentally illogical.

This is not a binary political debate. It’s a war. But unlike previous American wars that were fought in far off places bolstered by an American economy that was actually energized to support it, this one is being fought on our soil.

We’re not America in WWII. We’re France…complete with Maginot Line to the south.

We have the brutal task of defeating an external belligerent (the virus) and an internal one (economic collapse) at the same time. It might be an exaggeration to say this is America’s first total war on our soil. But not by much. And we need to fight it that way.

There are three fronts:

1-Fight the disease. Medical capacity, disease containment, therapeutic treatment, and…vaccine.

2-Provide financial sustainment. Over the top, New Deal scope programs that cover people, small businesses and corporations. Don’t make it an either or. Do it all. Do it for as long as we can.

3-Systematically open up society where we can and when we can. Maybe start with schools. Ask questions like what behavioral, technological and organizational innovations would be required to get kids back into school by September?

That’s it. That’s the fight. Anything else is a show.

Be wary of the political/media industrial complex pitching other topics. And be wary of politicians disguised as civic leaders using this war as a platform. If they aren’t talking about any of the three fronts in the war and what they are doing to deliver against them, it’s not worth the time.

The Occam’s Razor of Pandemic Response

(This is from a Twitter thread that grew into an essay. I’m pretty active in that domain so if interested feel free to follow here.)

From a covid19 response perspective, there’s been a lot of conversations about why some places did better than others and who is ultimately responsible for poor outcomes for populations facing the pandemic. Specific to initial pandemic readiness, I think things are actually simpler than we’re making it. There’s a bit of Occam’s Razor involved.

I’m not the first to suggest it but the notion that comparative pandemic response breaks down along the lines of Southeast Asia vs others is a pretty clear way to look at the problem. Adding variables doesn’t get us closer to the truth. It just adds noise. And so the actual solution to future pandemic outbreaks keeps getting paved over with other things.

It’s nearly impossible not to watch the daily Covid19 pressers and not imagine some sort of panacea that didn’t involve the current administration. Or even one that just made us feel a little better. A good contrast is clear in New York.

Governor Cuomo has an approval rating nearing 90% because he’s standing up and delivering the message his constituents want to hear. As a result they feel like things will eventually get better. It doesn’t change the reality that they weren’t ready either though. And like the rest of America, thousands of people will die who otherwise may not have. The contrast between Trump and Cuomo doesn’t account for where we are materially.

Like New York, Italy and Spain are in full outbreak mode with more absolute deaths than the U.S. with only 20% of our population. There is no Trump administration there. And they have universal healthcare. In fact, it’s safe to say the entire West was caught asleep at the switch with many different sorts of leaders with many different sorts of healthcare systems.

The variable for readiness isn’t Trump or universal healthcare, though both of those things matter tremendously going forward. And none of the politically energetic arguments can account for the difference in readiness between the West and the East. Nearly every effective response, South Korea, Taiwan, Singapore, China (if you can believe any version of their numbers) have all come from the same region. And it brings  a simple conclusion.

Southeastern Asia has more experience dealing with pandemic than we do. And so they’re better at it. We can talk about state capacity and authoritarian rule vs liberal but the simple reality is we in the West are pandemic rookies.

I live in Southern California. We have both a high Asian American population, high levels of Asian temporary residence workforce and a high volume of Asian tourism. I’ve been watching people from Asia walking around in crowded places in America with masks on for fifteen years. I’ve never seen anyone from anywhere else do the same. And frankly I always viewed the practice as unnecessary and alarmist…like nearly every western leader and much of MSM with Covid19. Because pandemic response was not a part of our contemporary culture.

SARS hit in China within a year of the 9/11 attacks in the U.S. There have been multiple Chinese outbreaks since that have stressed their system. None were severe enough to have the impact Covid19 has had. But they were all severe enough to drive action and build the muscle of pandemic response. In the same time period America has built up counter terrorism capacity in to the same extent. I was a part of it.

Remember the Boston Marathon Bombing in 2013? Boston locked down the entire city cheerfully until a joint task force of intelligence community, federal law enforcement and local police caught the bombers in days.

Not weeks. Days.

The American counter-terrorism muscle was and is that strong. Because we’ve spent the last 19 years exercising it. Southeast Asia has spent at least some effort getting better at pandemic response.

It’s telling that no one really cared when President Trump eliminated the pandemic response directorate within the National Security Council. We do now of course. And it looks like a terrible decision. I didn’t even remember it happened though. And I pay more attention than 99% of most Americans.

After we go through recession, have 30% unemployment and lose our personal liberty for three months in America, I suspect we’ll improve our response. This is some part of our identity. We are the “sleeping giant” after all.

It’s little consolation to those of us living through it now I know. The proactive response was a uniform failure in the West. Our energy is best spent on insisting the reactive response is effective and holding our leaders accountable for that.

The Capacity Problem of Pandemics

I’m an operations guy. I have been my whole professional career. I was an operations officer in SOCOM for the better part of a decade and for most of the last decade I’ve been doing some version of the same thing in the consumer software industry.

It’s hard for me to see problems through any other lens.

At it’s core, the art of operations is the activity of matching capacity with demand. There’s a X amount of a particular thing needed because there is Y amount of people/places/enemies who need it.

Figuring out exactly what the X and Y are isn’t really the art of it. That’s just math. The art of operations is understanding the levers that get pulled on either side of the equation to change the math. And understanding what forces move those levers and ensuring that, when the barbarian hordes are amassing at the gates, you’ve got the right levers in your hand to pull to address the ones that you don’t.

At the heart of the COVID-19 epidemic is an incredibly dire capacity problem. And the most common misconception that I’ve seen in the discussion about how to approach the pandemic, is a lack of understanding that capacity problems, at some point, cease to become a symptom of the problem and actually become the problem itself.

The impact from a mismatch of capacity to demand eventually consumes an entire operation. And once that happens, the train is off the track and it doesn’t get back on until demand subsides.

The only variable to control at that point is how many people who need something won’t get it. The grim assumption in pandemic is some higher than acceptable proportion of that group ends up dying.

Spending some time in the math of capacity planning, we can see quickly how shortages reach a tipping point and in pandemic how once that point has tipped, it’s so hard to get it back under control.

The entire acute health care capacity plan in America is based on one baseline assumption:

That an extremely small percentage of Americans will need acute care.

According to the Society for Critical Care Medicine (SCCM) there are about 97,000 ICU beds in America. At any given night, they are about 2/3 full. Which means the working forecast for ICU beds in America is grounded in the assumption that, at any given point in time, 99.98% of Americans will not need an ICU bed.

We have an excess capacity of about 32K beds. Which means that we can stretch our assumption to 99.97% of Americans not needing an ICU bed, without a problem.

Now here’s where the law of large numbers gets problematic for us in a hurry. Let’s say, for the sake of estimation, a hypothetical epidemic hits us and we can only really assume that, at any point in time, 99.9 percent of Americans can be depended on to not need an ICU bed.

This, .07% difference to the untrained, non operations forecaster eye, sounds like an extremely small number. In reality, represents a 400% spike in demand. And it results in a shortfall of 130 thousand ICU beds on any given night.

The clock never stops though. And now time is the enemy.

Say the hypothetical pandemic causing that spike lasts for 60 days. Then over that time, 7.8 million Americans who need acute care, will not have access to ICU beds. This shows how extremely small changes at the top of the demand funnel make for crushing outcomes at the bottom when you have a population of 330M. Based on this estimation, I can describe this problem two ways accurately:

This hypothetical virus will result in less than one tenth of one tenth of one percent increase in need for acute care.

Or…

Over the next two months, about 8 million Americans infected with the hypothetical virus who need acute care, will not get it.

The ops guy in me sees the problem the second way immediately and knows that I’ve got a problem. And my only hope is to address both sides of the equation. I need more capacity AND I need less demand. It will be insufficient to try to simply increase capacity. Because the good guys are playing the game with resource dependent arithmetic growth. The bad guys are playing with resource independent exponential growth.

Let’s unpack that.

When I make a new ventilator or a test or an ICU bed, the existence of that ventilator or test or ICU bed does nothing to increase my capability to to make more. On the contrary, it diminishes my capacity to make more because each one uses some amount of finite resources.

Right now the nation that put a man on the moon with slide rules and pencils doesn’t have enough long Q-tips to make COVID19 tests. This is the reality of where we are on increasing capacity.

On the other side of the fence, every person who catches the hypothetical virus can effortlessly spread the virus and infect countless others. The only resource the virus requires is an uninfected human. This is exponential growth. And it gets out of hand in a hurry. A penny that doubles in value every day is worth $5 million at the end of a month.

The hard part about handling exponential demand growth with arithmetic supply growth is that once you’ve fallen behind, it is impossible to catch up. In fact it’s impossible not to rapidly fall further and further behind. If you don’t stop the growth of demand, it doesn’t really matter what you do.

Social media platforms illustrate this gap effectively. Their customer growth is exponential. The more they have the more they get. Their ability to provide human support to those customers is arithmetic.

Ever try to talk to a person, real time, for help with a problem on Facebook? You can’t. They know they can’t provide it. So they don’t try. It’s a luxury social media platform have that the medical community doesn’t.

This is where the truly brutal nature of epidemic starts to materialize. My capacity is behind. I’m falling farther behind by the second. And then the virus actually starts to diminish my capacity to help the people I actually can. Because besides beds ventilators and tests, the capacity to provide care depends on humans to provide it. Now the virus and my operation are fighting over the same resource. And the virus is better…exponentially so. Eventually, they get infected. The gap widens even further until eventually capacity reaches near zero while demand accelerates.

Now the virus is no longer the problem. My lack of medical infrastructure is. I no longer have capacity to deliver services for other issues. And problems that are entirely unrelated to the epidemic can’t be addressed.

Now, I’m on the road to operational collapse.

It starts with eliminating elective procedures. And then I start to pull DEFCON levers that increase in severity until I’m making decisions on who lives and who dies. And then simply how long to shut down the whole operation because the declaration of no capacity is better than the unfilled promise of some.

All because of an increase in one tenth of one tenth of a percentage of demand for acute care.

In the operations world, nothing about that scenario is controversial. It’s the pattern we understand that defines why we do what we do. Where the controversy lies in every operations problem, is the math that gets you to solving the mystery of demand.

For COVID19, we don’t know what the baseline infection rate is. And we don’t know the impact efforts to limit it will be.

These are all common forecasting problems. The way we get around them is through the collection of historical arrival patterns and the collection of massive data sets that allow us to use machine learning algorithms to enable more effective predictions.

We don’t have historical COVID19 data. And we don’t have nearly enough real time data to start to feed ML platforms that can help. And we won’t until it’s too late. So we’re left with the mother of all bad operations problems.

We have a huge area to cover. We have an unknown incidence of events to respond to. And we have extremely limited resources to respond.

As an Ops guy, I’m out of precise, limited measures. The only action I can take is 1-Broad measures I know inherently decrease demand. 2-Rapid production of capacity.

Right now the bets we’re making are on the forecast. And I can tell you from experience that we don’t have enough data to know that it’s accurate. People telling you X people will die don’t know. People telling you Y people won’t die don’t know.

So we’re in a place we’re we have to decide something undecidable. Which means we really have to fall back on principles that allow us to answer the following question:

If we’re wrong, and we most certainly are to some degree because we don’t have enough information to be right, what’s the acceptable damage we’re willing to incur?

Is it worse to have to simply shut the operation down?

Or is it worse to do the things it requires to keep it running?

This is the question every ops person answers on their way out the door when it’s gotten to bad to stay. And it’s the one on the table for world leaders now.

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