Life is short, the art long, opportunity fleeting, experiment treacherous, judgment difficultFirst Aphorism of Hippocrates
The first treatise on ‘epidemics’ is attributed to Hippocrates, the Greek physician who lived 25 centuries ago, invariably described as the ‘father of modern medicine.’ He gave the word its medical meaning as a disease ‘which circulates or propagates in a country’. Historians of medicine have debated whether his description of the ‘Cough of Perinthus’ is the first of an outbreak of influenza, or was really about diphtheria. It was most likely a reference to a collection of diseases notable for their winter onset and their dynamic quality. Thucydides had already provided his own vivid account of the ‘Plague of Athens’, that took the life of his hero Pericles and almost his own, killing 25 percent of Athenians, and coming in waves, returning twice after making its first devastating appearance. Although Thucydides claimed that physicians were helpless in the face of the plague, some accounts credit Hippocrates with curing it by lighting fires to fumigate the air.
Hippocrates also introduced the idea of a ‘crisis’. This was central to his theory of how diseases progressed. At some point, often unexpectedly, a decisive moment would come in a patient’s battle with a disease. Once this moment passed the result of the battle would be known. The patient would either be dead or recovering. The concept remained influential in the centuries following Hippocrates. Crises continued to be identified by doctors as inflection points that were apt to arrive suddenly with little warning. A common example would be when the sort of fever associated with pneumonia rose to dangerously high levels and then either abated or consumed its victim. There was a natural drama to such moments which is why they often appealed to novelists. Vivid descriptions of attempts to soothe and calm delirious and distressed heroines were mainstays of 19th century fiction, appealing to sentiment and also serving as a metaphor for the thin line separating salvation from disaster. In Sense and Sensibility Marianne Dashwood recovers; in Little Women, Beth March sadly does not.
By this time ‘crisis’ had migrated into general use, describing any situation in which a decisive change, for better or worse, was imminent. Instead of high fever the non-medical symptoms were chronic insecurity, compounded by the pressures of time. Irresistible forces hurtled towards immovable objects. A future that had recently been viewed with confidence was now clouded with uncertainty and full of danger. Economic crises came to be associated with financial panics, with runs on banks, or sudden losses of business confidence leading to stock markets crashing. For students of international relations the continual possibility that independent states, wary of each other and jealous of their interests, might collide made crises a natural way to depict those tense confrontations which could end with either a lurch into war or reversion to peace.
By definition a crisis was not a hopeless condition. Salvation was possible. Some unexpected development could swing the situation back to safety. An ingenious plan might be devised to retrieve the situation. During the Cold War, when war was likely to lead to a nuclear catastrophe, it was realised that it was both necessary and possible to prepare for crises in advance so that not too much was left to chance. Crisis management was raised to the level of a vital strategic art, requiring a pragmatic combination of resolve and flexibility. Crises tested a leader’s character in a way now associated with President John Kennedy during the 1962 Cuban Missile Crisis. This episode more than any other forged our image of a true crisis, with stressed governments, emergency meetings, exceptional measures, regular news bulletins, anxious waits, and time running out as the decisive moment approaches. It was also a crisis that ended without calamity. So long as it does not break in the wrong direction, a crisis can therefore be a time for creativity and determined, innovative action. At times of crisis we do not expect governments just to ‘wait and see’. We expect action. We are uncomfortable with the idea that some situations are beyond our control.
The great Covid-19 pandemic appears as a crisis in both the medical and non-medical senses. It is about a disease which hits individuals almost along Hippocratic lines, with the critical day coming after about a week, when the patient’s condition either deteriorates or improves. Boris Johnson conveyed this meaning when he recalled the moment when he was in intensive care at St Thomas’s Hospital with Covid-19 and ‘it could have gone either way’. The pandemic’s own dynamic is a function of the numerous individual cases, with permutations of symptoms, infectivity, resistance and severity. The coronavirus can lurk around for days and weeks before suddenly growing quickly and getting a grip on a population. In just over two months it moved from being observed in the Chinese city of Wuhan to almost overwhelming the health care systems of Europe and North America. Each separate health crisis became a political crisis, as governments scrambled around to find ways to suppress the inexorable, exponential growth, desperate to prevent the situation getting away from them.
All this required an aggravated form of crisis decision-making. All decision-making is conducted by fallible human beings working in flawed organisations with inadequate information. Crises are extreme cases, when these fallibilities, flaws and inadequacies are more on display than usual. Walter Bagehot, writing of The English Constitution in 1867, spoke of how a ‘great crisis’ required the ‘pilot of the calm’ being replaced by the the pilot of the storm’. More ‘daemonic’ qualities would be needed of a sort that could be harmful in normal times – ‘the imperious will, the rapid energy, the eager nature’. With a crisis the time pressures are intense, with incessant demands for quick decisions that have to be made on the basis of patchy evidence, still subject to interpretation, and cursory evaluations of alternative options. The decisions have to be made in a media spotlight, propelled forward by occasional injections of panic, and taken despite fatigue. Yet the decisions must also be presented with a show of calmness approaching sanguinity so as not to spread alarm. Almost inevitably they end up focusing on symptoms more than causes, short-term impact more than long-term consequences.
And yet, even with all the stresses and strains, crisis decision-making can also be liberating. The imperatives of the moment drive the process. Policies that were previously unthinkable become unavoidable. No one dares restrict vital spending. Bureaucracies are galvanised into action. So long as the public appreciates the gravity of the situation, and something potentially effective is being done, it will be tolerant and supportive. Even though aware of past mistakes – and if there had been none surely there would now be no crisis – the public also wants to see the situation under control and a return to relative tranquillity. And in this respect Covid-19 provides a spectacular example of crisis decision-making: barely three months after the first symptomatic cases were identified, a collection of governments, varying in so many respects, many normally cautious and risk-averse, effectively shut down their societies and economies.
All crises end with a reckoning as the costs are counted and the bills reach the Treasury. In this case the costs cannot be set so much against any tangible gains but instead against the even greater losses averted. More seriously they are still being accumulated. Although in May governments began to take the first tentative steps to ease the stringent restrictions imposed in March, caution and risk aversion is now back in play. They might look forward to a day when the great pandemic could be officially declared over, when the coronavirus will have run its contagious course, when vaccinated people will gather and greet, travel and work, when economies will move back into a high gear, and investors find sufficient optimism to start placing bets on new ventures. But they are not there yet.
The trauma of the first half of 2020 will leave an indelible mark, but it is only the first of a number of stages. We cannot be sure what will come next. In some countries the virus may be down but it is certainly not out. The virus’s reproduction rate may have been successfully suppressed to below 1, permitting experiments with normality, but it would be something of a stretch to describe the situation as being under control. Treatments are still being explored. Only mass immunisation will provide a sure relief, and that may well not arrive until 2021. It could all come back again.
Hippocrates distinguished between perfect and imperfect crises. With a ‘perfect’ crisis the sick person would either die or recover completely. It was known to be perfect when the symptoms of recovery were favourable, clear, secure and trustworthy. With an ‘imperfect’ crisis the recovery was incomplete and there was the possibility of the disease recurring in the future. Hippocrates linked this question of perfection and imperfection to his concept of a critical day, a fixed time after an illness was contracted. A crisis on this day was likely to be perfect. On other days it would be imperfect. Even if the patient emerged in an improved condition there was the possibility of a relapse into an even more dangerous condition. In this respect, the great pandemic of 2020 is an imperfect crisis.
One of the most famous descriptions of an imperfect crisis in international relations is E.H. Carr’s The Twenty Years Crisis, published in 1939. Carr’s book was about the interplay between utopianism, which required that the world be made to fit to an imagined ideal, and realism, which took the world as it was and made the best of it. Carr blamed utopianism’s refusal to come to terms with questions of power and interest for another war starting some two decades after the previous one ended. Instead of resolving the question of war, the effort set in motion in 1919 to create a harmonious world without war had led to one crisis after another. To help make his point, Carr quoted a 1938 comment from former British Foreign Secretary Anthony Eden:
It is utterly futile to imagine that we are involved in a European crisis which may pass as it has come. We are involved in a crisis of humanity all the world over. We are living in one of those great periods of history which are awe inspiring in their responsibilities and in their consequences. Stupendous forces are loose, hurricane forces.
In an imperfect crisis the period up to the first critical point results in an unsatisfactory, indecisive outcome and may not lead to recovery, at least not until another critical moment is reached and possibly not even then. Carr described his book as an attempt to ‘navigate … relatively uncharted waters’ and this is what we need to do with the pandemic. This goes beyond the observation that it is not yet over so it should be viewed as a ‘marathon and not a sprint’. It requires a different sort of mental picture of where we are and what might be coming.
The first picture was of single curves. These curves represented for individual countries the numbers of daily cases, hospital admissions and fatalities rising and falling. Peaks were reached, usually quite quickly, and then there was a decline, usually more slowly. Governments described the key aim as one of ‘flattening the curve’ to prevent their health services being overwhelmed. Because some curves were flatter than others this encouraged a natural search for explanations as to why this might be so. In the UK, which had one of the more mountainous curves, there developed a standard form of comparison, common on social media, noting that in other countries, with curves more like gentle hills, particular interventions were made (say effective testing and contact tracing, early lockdown, or screening and quarantining). The implication was that if only the UK had adopted this intervention in a timely fashion then its curve would look a lot flatter. On Twitter correlation is King and causation languishes in exile.
It is not, however, the case that absent any interventions all countries would have had the same experience so that all curves would have looked the same. The coronavirus did not affect all countries in the same way. It was capricious. It hit Brazil but not Venezuela, devastated Teheran but largely left Baghdad alone. A number of factors influenced these curves from the start. A young population certainly helped. So did geographical isolation, between countries and within them. Fewer travellers meant less transmission. Luck also made a difference. Thus one part of the explanation for the dire numbers in the UK, in addition to policy errors and inadequate testing, was the dominant role of London, the largest city in Europe, deeply connected to the rest of the world, through a range of networks. Cities tend to high population densities, constant mobility, with areas of relative deprivation, all of which make them susceptible to high rates of infection. Another was the misfortune in having people taking their half-term breaks in Spain and Italy at just the wrong time, seeding infections across the country. A number of possible explanations might be advanced for Germany’s relative success in keeping down the death toll: Berlin is half the size of those other cities, but it was also closed down before the others. There was an extensive testing programme, but the virus also appeared to have entered Germany through a younger demographic.
When it comes to South Korea the best explanation of its ability to get an early grip on what looked like a dangerous outbreak was the fact that not only was it linked to a religious cult, but an early realisation that it was both possible to quarantine this group and isolate it from the capital Seoul.
The curve left us fixated on a single peak. But we have an alternative metaphor with waves, inherently dynamic and with one always followed by another. The epidemiological models with which we entered this crisis show waves. Not just a single wave, rising to its crest and then subsiding, but a series, and with the awkward possibility that the more the first wave has been suppressed the bigger the waves to come. The models assumed that any given population would be equally susceptible to the coronavirus, taking account of the much more severe impact on the elderly. In this respect if, whether by good luck or good management, infections were kept down in the first wave then the population would be left more vulnerable to a second wave simply because there would be less immunity. It was the case, for example, with the Spanish Flu that the second and third waves were worse than the first. The experts in virology and public health keep on warning that if we do not stay alert and maintain a degree of social distancing then later in the year, perhaps this time mingled with seasonal flu, the coronavirus will come back with even greater force.
There were therefore natural worries as restrictions were eased that the first wave was not yet over and that too quick a return to ‘normality’ would simply invite further outbreaks, undoing whatever good might have been achieved with the early stringency. Governments were criticised for failing to alert their people until it was almost too late about the consequences of the onward transmission of the coronavirus from China to their countries. They must now alert people to the possibility of it making a depressing return and dampening down optimism that the worst is behind us and that the position from now on will only improve.
Governments surprised themselves with what they asked of their people, and how well they complied. But can they be sure of the same response if they have to ask again? Just as the first wave appeared in a variety of forms this is also likely to be the case with the second. How individual countries will fare will depend on permutations of the (possibly changing) properties of the virus, demography and geography, luck and policy. Sweden, for example, while requiring some social distancing, chose to endure a tougher first wave than their neighbours in the belief that mass infection would confer future immunity. For the moment the first wave has proved to be tougher than expected without there yet being grounds for confidence that that a sufficiently large proportion of the population has become immune to limit future transmission. It is certainly not yet a ‘herd’. A number of American states decided that the economic costs of lockdown were too great and that those that might die as a result of a looser regime are collateral damage, and possibly not greater in number than those for whom a severe economic recession may yet prove fatal. A number of those are now showing significant numbers of new cases.
Some, for example New Zealand, that not only locked down early but also benefit from their isolation, expect that their advantage will enable them to react quickly to any early infections and so keep them down. It may be that those populations coming out of a bad experience will be more vigilant in the future and stay wary of crowds and close contacts. Those that got off comparative lightly may be more relaxed and ready to take risks. And then of course the optimists hope that a vaccine can be developed quickly. So instead of the neat, regular sine wave of the models, Covid-19’s future appearances might involve steep gradients, sharp spikes, occasional bumps, slight perturbations or nothing at all. This is why this is an imperfect crisis. A peak was reached and recovery began but it was less than complete and the disease has not been eliminated and may return with greater ferocity although possibly less. But it is also an imperfect crisis for another reason. The health crisis has triggered an economic crisis that will be longer lasting and even more deadly and disruptive in its effects. This will have its own dynamic that countries will address in distinctive ways, although they will benefit from international cooperation. The health and economic crises will continue to influence each other.
The economic crisis has made itself felt through its own curves, with debts and unemployment moving sharply up as economic growth and investment move sharply down. These are not so much curves as steep cliffs, and despite early talk of bouncing back in a ‘V-shape’ until there is confidence in a sustainable health recovery there is likely to be only a modest economic recovery. If more severe outbreaks of Covid-19 cases are on the way then countries already heavily indebted may find it difficult to operate at the same level of resources. Or take the dog that has yet to bark in this crisis or is only starting to be heard. Most pandemics find their way to the developing world where they cause the greatest carnage. It is not the case that the countries of the southern hemisphere have escaped completely – Latin America is emerging as a major centre of the epidemic – but most have yet to be hit to the extent that would have been predicted from past experiences. This may well be the result of their youthful populations. One of the most important questions for the rest of the year is how much this continues to be the case. But developing countries are already suffering economically, both from their own precautionary lockdowns and the recession enveloping the developing world. Will their populations be so well placed to withstand the coronavirus in the future if it has been weakened by poverty and food shortages? Moreover economic shocks are generally bad for health. Whatever the virus gets up to poorer, hungrier, stressed people will become vulnerable to a range of ailments.
And then there is going to be a third crisis, a consequence of the instability caused by the health and economic crises. Within and between countries there are the symptoms of political crisis. Governments see their performance scrutinised and will be challenged over poor decisions. Electorates may veer away from relief and resilience to a more explosive mix of anxiety and anger. Within the EU solidarity will be tested. Relations between China and the US, already poor, have been aggravated. If governments start falling and conflicts are aggravated then we are in for an even worse time. At the same time political crises should also be amenable to leadership and innovative thinking. The political crisis has yet to reach its fever point and how that is resolved will be the most critical for the future. So long as it is survived then it should be possible to do a better job on the health and economic crises. With imperfect crises there is no prospect of early salvation. But nor do we need to consign ourselves to fate as if it has all become too much.