Commentary: Knowing the unknowns

Updated: Jul 17



Helmy Haja Mydin


To paraphrase the former United States Secretary of Defence Donald Rumsfeld, there are known knowns, known unknowns and unknown unknowns.


As much as it may sound of gobbledygook, his comments can be applied to many situations including the developing novel coronavirus epidemic.


Known knowns

A form of the coronavirus that was hitherto unknown — hence the term “novel coronavirus” or nCoV — was identified in the Chinese city of Wuhan towards the end of 2019. Having most likely originated from animal sources, it is from the same family as the viruses that caused the Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS).


Individuals affected appear to have symptoms very similar to patients with influenza. These include high fever, coughing and breathlessness. Pneumonia occurs in some cases and in very severe cases, multi-organ failure develops. There is no specific cure for the disease — healthcare workers support the body whilst waiting for the body’s immune system to fight off the viral infection.


As of the 29th of January 2020, there have been more than 6000 cases worldwide, with the vast majority in China and others spread across more than a dozen countries. Of these, there have been more than 130 fatalities, mostly from the Hubei province. There is increasing evidence of spread between human beings, with people who have never visited China falling ill in Germany, Japan, Taiwan and Vietnam.


Known unknowns


There are two major concerns when dealing with infectious diseases — how easy it is to spread and how dangerous the disease is. For example, the common cold and conjunctivis or “pink eyes” spread very easily, but they rarely lead to severe disease and fatality.


For influenza, America’s Centers for Disease Control and Prevention estimates that there were approximately 810 000 hospitalisations with 61 000 deaths. MERS-CoV is less contagious but is even more severe, with 35 per cent death amongst the approximately 2,500 confirmed cases.


The evidence for nCoV so far seems to indicate that it spreads relatively easily, but is not particularly severe. The mortality rate seems to hover just below the 3 per cent mark, with most deaths associated with the elderly or those with underlying chronic diseases.

The numbers are likely to rise significantly over the next few weeks. It is also worth bearing in mind that those who have mild symptoms are unlikely to seek medical help and may not be diagnosed.


The real number of cases may thus be far higher than what the data indicates, which also means that the mortality rate may not be as high as suggested. However, we will not know the true extent of the “spreadability” and severity of nCoV until the situation stabilises over the next few weeks.


The manner in which we respond collectively will also have a huge consequence on the economy. Oftentimes fear and anxiety have greater impact than the disease itself. While the manufacturers in healthcare products such as medicines, gloves and masks may see an increase in sales, nations’ balance sheets will be tipped into the red by increased public healthcare expenditure and a dip in travel, leisure, retail and energy consumption. The degree to which we are affected will depend on the severity as well as the duration of the perceived emergency.


SARS cost the world economy approximately USD40 billion, and was felt by more than just the countries with positive cases as the world’s interconnected financial services and economies means that a domino effect takes place even if only a minority of countries in the supply chain are directly linked with the disease.


Unknown unknowns


The world’s increasing connectivity is both a boon and a bane. The Chinese government has obviously learnt a lesson from the SARS epidemic and have been very forthright in the sharing of data. It took a grand total of one day for the World Health Organisation to be alerted which has led to unprecedented levels of data sharing and analyses at an international level.


High levels of transparency has led to quicker diagnostics, genome sequencing and reporting. It is hoped that this will lead to faster identification of treatment options and creation of vaccines.


However, there is definitely room for improvement. Data can be shared in real time, with health ministries across the world sharing more granular data using HTML tables or CSV.

Sharing infographics and visuals are helpful for strategic communications and public education, but do little to capitalise on the opportunity to crowdsource analytical prowess.

While identification of confirmed cases is no doubt useful, we have the technology to do predictive analyses if sufficient good data is made readily available. This will not only guide the allocation of finite resources, but as with other experiences from machine learning, might uncover unexpected patterns that may prove useful in managing the epidemic.

Digital connectivity has allowed healthcare workers to share treatment regimes and guidelines, but it has also bred large online clusters of misinformation and fake news that arguably spread even more rapidly than the nCoV. It is unfortunate that those with xenophobic and racist views have taken to stage to spout vitriol that is ostensibly a result of fear and anxiety.


The degree to which this impacts society is difficult to predict, as the consequences will be felt both online and offline.


Moving forward

Fear is a potent paralytic agent, particularly when faced with the new and unknown.


Malaysia’s Ministry of Health has been doing a commendable job of addressing concerns raised by the rakyat. It should continue to increase efforts at communicating in a timely and consistent manner, alongside the rest of the government machinery.


It is not too early to identify weak spots in the handling of the crisis so far. These will allow us to avoid repetition and to ensure that future crises are dealt with in as efficient and effective a manner as possible. The nCoV is not the first respiratory virus epidemic, and it is definitely not going to be the last one.


This article was originally published in the Malay Mail Online.

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