COVID 19 A MASTER CLASS IN EXPONENTIAL GROWTH

02 May 2020

COVID 19 – How did the world get caught flat-footed? A lesson in exponential change met with a linear response.

COVID 19 thus far has infected nearly two million people worldwide; over a hundred thousand have died and brought the world to a standstill. Some like Bill Gates see this pandemic coming, but most governments ignored the warnings. There were plenty of warning signs - SARs, Swine flu, MERs, and Ebola.

In just one month since it was declared a pandemic on 23 March 2020, COVID 19 has managed to turn the world upside down and wrecked the global economy. The immediate grief and suffering of this infectious disease is a precursor of even greater misery from a deep global recession or worst a depression over the next few years. Right now, we are living the first part of the Hollywood movie Contagion. How did the world get caught so flat-footed?

Exponential growth, linear response, result in a CHASM

The explanation is quite simple. COVID 19 moves at an exponential rate while global responses were and are still linear. COVID 19 is reported to have a reproduction rate of between 2 to 3, that is exponential growth.

One of the common stories used to explain the meaning of exponential growth relates to a chess game between an Indian king and Lord Krishna. The king agreed to grant the deity any reward for beating him. The deity asked for a single grain of rice on the first square and doubled it on every consequence square. Having lost the game, every square on the chessboard started to be placed with rice as agreed. The king was to have his lesson in the power of exponential growth – 1 grain of rice in square one became over 1,000,000 in the twentieth square, and by fortieth first square, he was looking at over 1,000,000,000 grains. There are 64 squares on the chessboard, you can do the math.

The exponential growth curve starts slowly, gradually, and then suddenly, as the king found out. When the curve reaches the suddenly stage, its impact will be disruptive. The graph above plots the trajectory of the exponential curve of COVID 19 and the linear global responses in three stages:

In the initial stage, the seemingly slow rate of infections of COVID 19 was very deceptive and gave grounds for complacency.
When COVID 19 reached the “hockey stick” part of the curve, its rate of change is already faster than sluggish linear global responses. In January 2020, the Chinese numbers of infected and fatalities, even if it was understated, should have had alarm bells going off around the world. The WHO did sound the alarm, but few countries paid attention.
Once COVID 19 crossed the "tipping point," the linear responses were never going to catch up. The “chasm” widens with each passing week for countries like Italy, Spain, France, UK, and the USA. Confirmed infections and death continue to rise into the thousands as the epic center of COVID 19 shifted from country to country.

Without an effective vaccine until the end of 2021, countries hope that drastic responses like border closures and lockdowns can slow down COVID 19 exponential growth. These drastic border closures and lockdowns are governments shifting their responses to a different gear. But can it match and keep up with COVID's exponential rate of growth and change?

The Chinese lockdown suppression strategy seems to be working after about two months. The South Korean exponential response largely anchored on extensive testing, contact tracing, quarantine, and isolations also appears to achieve similar favorable outcomes in tackling the first wave of this pandemic. In both these countries, COVID 19 exponential trajectory seems to have slowed down considerably. This is largely due to efforts made to break COVID 19's transmission chain. New cases and death have dropped dramatically compared to two months ago. However, both countries are vigilant of a second wave from imported and asymptomatic cases.

Foundations for exponential response

Major lessons have already emerged as many developed countries throw unprecedented resources to fight COVID 19. Pre-requisites for an exponential response include (1) major investments that need to be made in key areas of capacity and capability before a pandemic hit, and (2) ability to activate, scale and pivot these investments.

The three key areas of capacity and capability needing major investments are:

Infrastructures - adaptive, open and can be scale exponentially
Leaders and teams – trained to respond effectively to complex, ambiguous, fast-moving, and constantly changing threats.
Social capital

Investment in infrastructures

The obvious infrastructure investment required is the countries health systems. The need to invest in more hospital beds, ventilators, and personal protection equipment (PPE) has been well covered throughout this pandemic. Equally important are investments in surveillance systems, public health promotion and protection capabilities, primary care and diagnostic, therapeutics, and vaccines development platforms.

Investments in intelligence and surveillance systems are equally important before, during and after any infectious disease outbreak. Early detection and surveillance need to address the pre-conditions that allow, for example, zoonotic pathogens to explode out of their natural environment into ours.

Leaders we need

The art and skill of leaders to lead in a pandemic need to be trained, practiced, and can be deployed on short notice. We need leaders who can govern and lead teams. In a crisis like a pandemic, we need leaders who can make quick, decisive, early, and probing decisions. There is plenty of spectacular examples of the failure of leadership in the handling of COVID 19 to-date. There are a few leaders that have provided us with an early exemplar of what it takes to tackle a pandemic. However, these are early days, and leaders we need have to last the distance. To do so, they must possess the following attributes:

Team player and a broad network of collaborators
Make decisive, clear, and timely decisions, often with incomplete information.
Able to see the big picture.
Adapt, change, accelerate, pause, slow down or stop
Courage and calm under fire
Inspirational and excellent communicators on what matter.
Bringing the population along for a marathon journey
Excellent in getting things done

Social capital

Social capital, in broad terms, describes the relationships between individuals, communities, and institutions that build trust and respect based on shared values.

To break the transmission chain of COVID 19, governments have closed their borders, restrict population movements, closed schools, places of work, recreation, and ask people to stay at home. For these intrusive and disruptive measures to work government requires the goodwill, cooperation, and sacrifice of the general population.

Governments are drawing on social capital big time when they put society into lockdown. The most comprehensive and well resource pandemic plan led by the best of the best leaders will still fail if there is insufficient social capital to call on. Social capital needs to be constantly nurtured, developed, and build up in "peace" time. When a country goes to war with COVID 19, and the government takes these drastic lockdown measures, there is social capital depth to draw on. The amount of sacrifice that the general population will make will almost be entirely dependent on the depth of its social capital.

Governments' multi-billion or trillion stimulus package is designed to take some of the edges of the sacrifice made by ordinary people and businesses. Such packages will only have meaning and impact if there is a strong social capital foundation.

Activate, scale and pivot

When faced with a threat that moves and changes exponentially, responses activation, scaling, and pivoting need to be exponential as well. There is no room for navel-gazing, pontification, ignorance, decision paralysis, and political point-scoring.

COVID 19 exponential threat, even in Stage 1, needs to be met with a response activation that is deliberate, decisive, and with overwhelming surge capacity. The COVID 19 Stage 2 exponential acceleration needs responses that can scale and pivot simultaneously at exponential speed. Asymptomatic, pre-symptomatic transmission and possible reinfections are prominent second wave challenges that require existing responses to pivot and change quickly. China, South Korea, and Singapore are three countries at the frontline of this pandemic's second wave.

Scaling and changing “testing” – a tangible example of the exponential response

Testing holds the key to defeating COVID 19. The activation, scaling, and pivoting of testing capacity is a good example of many country sluggish linear responses to this pandemic.

The RT-PCR test is the main workhorse to confirm infection of suspect cases by testing for the presence of the virus. This test requires specimens to be collected from a deep throat or nasal swab. Test specimens are sent to the laboratory to test for the presence of the virus in the specimen. This molecular PCR test can provide an answer in a couple of hours. This test is very sensitive and accurate but can give false negative if the specimen is taken too early in the infection, and there is insufficient viral load in the throat area.

Testing, even today in many countries, is only for symptomatic cases. In order words, a person needed to have symptoms before they can be tested. There is a real problem because it has been known for some time that asymptomatic and pre-symptomatic cases can be infectious. This gap in testing is a very clear example of the inability of the current response system to scale and pivot when new information becomes available.

The reality is most health systems are unable even to scale up testing capacity to cope with symptomatic cases. Shortage of swabs, reagents, PPEs, laboratory equipment, and trained staff are common reasons (excuses) cited by many countries for restricting access to testing even for some symptomatic cases. This is a very simple and clear example of a health system's inability to activate and scale even with tests that we are already using. When it comes to activating, scaling, and pivoting to use newer antibody and antigen tests, the report card is not much better if not worst.

The antibody test is used to detect whether a person has been infected by the presence of antibodies in blood samples taken. A person's immune system generates two types of antibodies to combat the SARs_CoV2 virus. This test is most suitable for surveillance screening rather than testing for active infections for treatment. Antibody tests and results reporting can be delivered from a simple POC device or from a complex laboratory depending on the level of surveillance required. Answers for antibody tests can range from minutes to hours, depending on the level of surveillance required. For COVID 19, this test is most effective after antibodies have been produced by the immune system. In the case of COVID 19 this takes about 9 to 14 days.

The antigen test is another test to detect the presence of the virus. Deep throat swabs are tested for proteins associated with the virus using point of care devices and results available in minutes rather than hours. This test is considered by the WHO as still too new for mass utilization but can be used for research and trial purposes.

While many countries continue to struggle to scale even the workhorse RT-PCR test, a few countries like South Korea and China are standing up an exponential testing program with capabilities that include:

an enhanced RT-PCR test capability to test for people infected and showing symptoms. Fast activation of greater laboratory capacity and new ways of taking swabs (drive-through, testing booths, and mobile testing stations).
Rolling out trials of antibody tests that would provide surveillance information of community infections from symptomatic, pre-symptomatic, or asymptomatic cases.
Rolling out trails of point of care antigen test that would test for people who are pre-symptomatic or asymptomatic carriers.

Other countries like Germany and the UK1 are other examples rushing to fill the testing gap by putting in place an exponential testing program.

Final word

COVID 19 is vividly demonstrating the meaning of exponential growth. Governments' responses, on the other hand, is woefully linear. Lockdown measures are not an exponential response to COVID 19. It is a crude, blunt, hammer used to "eliminate or suppress the" SARS-COV2 virus. It is wrecking people's livelihood and breaking rice bowls the world over. It is being paid for by the sacrifice, suffering, deaths of ordinary people, health workers, and other first responders.

To para-phase a granddaughter quote of her 93 years old granddad who died from a panic attack because he could not cope with local lockdown restrictions. "My granddad died not with COVID 19 but because of it. My family hopes that granddad's sacrifice will save other people's lives."