The Covid-19 crisis caught most countries unprepared. PPEs (personal protective equipment) for healthcare staff, masks, ventilators, isolation facilities and ICU beds were in short supply in cities across the world from Milan to New York.
This unpreparedness has undoubtedly resulted in a vast number of avoidable deaths.
Why did countries not prepare?
When we talk of countries we really mean governments. The invisible hand of the free market is great at providing a profusion of both necessities and luxuries at ordinary times. But it has no built-in mechanism to take care of pandemics. A profit seeking private healthcare provider may plan for ordinary seasonal surges, but can never afford the kind of overcapacity that planning for a pandemic entails. Only governments can do this.
So why did governments fail to plan for this pandemic? Even after they knew about the crisis in Wuhan? Even after the WHO warning? What were they thinking?
The branch of mathematics known as Game Theory provides part of the answer.
Epidemics can be viewed as a game between government planners and nature.
The government makes the first move in the game. For simplicity assume that it can make one of just two possible moves; it could prepare either minimally or adequately for an epidemic. Nature’s counter-move consists of unleashing a virulent or mild epidemic.
The above matrix represents game outcomes. Minimal preparation and a virulent epidemic results in many avoidable deaths; however if the epidemic turns out to mild, minimal preparation would be sufficient and save much money. Adequate preparation would save lives the epidemic turns out to be virulent but waste money if it is merely mild.
If the epidemic is seasonal or recurrent in nature (e.g. like common flu, dengue or malaria) than statistical analysis could be used to guide the government’s decision. In fact, the game would in that case fall in the domain of statistical decision theory.
Unfortunately, if the epidemic is new, it is extremely hard to judge in advance its virulence. This was the case with Covid-19.
But shouldn’t governments have planned for the worst-case scenario? Banned large gatherings and travel? Stocked up on masks & PPEs? Bought more ventilators and built more isolation facilities? Just in case the epidemic turned out to be serious.
Unfortunately such a strategy would often turn out to be suicidal for politicians, especially in democracies.
Consider the cautionary tale of Ms. Roselyne Bachelot.
She certainly did not ignore the WHO alert regarding the novel coronavirus pandemic and ordered over a billion masks.
Yes, that’s right. Over a billion masks. 1.7 billions to be precise.
However, I am not talking about the current Covid-19 pandemic.
On 11th June, 2009 WHO raised the worldwide pandemic alert level for novel influenza A (H1N1)virus to Phase 6 — the highest possible level. It would be the “biggest pandemic ever” warned Margaret Chan, the then WHO chief.
A vaccine was available but it was new and in short supply.
Roselyne Bachelot, the then health minister of France, took WHO’s warning seriously. Apart from masks, she ordered 94 million vaccine doses from several drug companies (Baxter International, GlaxoSmithKline, Novartis, Sanofi-Aventis) as well as over 30 million doses of anti-virals.
By November the infection was accelerating in France with 68 deaths till then including 22 in a single week. A study suggested that up to 20% of France’s population could be infected. Ms. Bachelot’s prudence seemed amply justified. The vaccination program was under way with two vaccine doses being planned for everyone in France.
However the vaccination program hit a snag when the vaccine was found to have some serious side effects. It was decided that only vulnerable people such as patients with other illnesses and healthcare workers would be vaccinated.
In any case the epidemic had passed its peak by mid December and France tried to cancel the order for half the vaccines. The stock prices of companies which had been contracted to manufacture the vaccine tumbled.
By March the epidemic was over. Less than 10% of the French population had been vaccinated.
Post pandemic analysis suggested that H1N1 was no worse than common or seasonal flu. In France about 310 people died from the virus. 21 died from adverse effects of the vaccine.
The vaccination program alone cost 674 million Euros. The overall cost of France’s pandemic preparation was close to 2 billion Euros.
Ms. Bachelot was accused of wasting public money and befriending pharmaceutical companies. Several opposition politicians demanded her resignation. She had to face an inquiry committee. Her political career was essentially over.
The stored masks were eventually burned and never replenished. The French sure wish they had them when another novel coronavirus came around ten years after H1N1.
Of course game theory is only part of the answer. It is complemented by wilful blindness and wishful thinking. Since adequate preparation would have involved costs they did not wish to incur most politicians convinced themselves that the Covid-19 outbreak would not be serious. This was WHO calling wolf one more time.