The Kerala dialogue on COVID-19

The Indian state of Kerala has taken an especially active approach to responding to the COVID-19 pandemic. Kerala, a state of more than 33 million people, is governed by the Left Democratic Front, having won state elections in 2016. LDF is a coalition of left-leaning parties, led by the Communist Party of India-Marxist and the Communist Party of India. The Kerala government has been consistently focused on equity and progress for the poorest sectors of Kerala society. Significantly, the government’s efforts in response to the COVID-19 crisis have fallen into the arenas of both public health and social wellbeing. The government quickly implemented public health strategies recommended by the WHO for responding — test, trace, quarantine — very early in the pandemic in Kerala, more quickly and consistently than the national government. Here is a nice summary by Sonia Faleiro in MIT Technology Review (link). 

In Kerala, a different style of leadership was on display. With 15 cases now confirmed across the state, Pinarayi Vijayan, the chief minister, ordered a lockdown, shutting schools, banning large gatherings, and advising against visiting places of worship. He held daily media briefings, got internet service providers to boost capacity to meet the demands of those now working from home, stepped up production of hand sanitizer and face masks, had food delivered to schoolchildren reliant on free meals, and set up a mental health help line. His actions assuaged the public’s fears and built trust.

Kerala’s experience with the pandemic has been much better than other states in India. Here is a comparison table with four other states in India as of June 30, 2020, normalized to cases and deaths per million. The comparison is striking. Kerala has less than one death per million, compared to 67 deaths per million in Maharashtra (the state in which Mumbai is located), and 141 per million in Delhi.

A crucial part of the success in Kerala in limiting the impact of the pandemic was the government’s early recognition that the pandemic would have disastrous consequences for poor people in the state. The government implemented emergency programs of food and stipends to offset the economic disruptions created by the epidemic. Faleiro describes the social sustenance program implemented in Kerala in these terms:

Vijayan, the state’s chief minister, was the first in the country to announce a relief package. He declared a community kitchen scheme to feed the public, and free provisions including rice, oil, and spices. He even moved up the date of state pension payments. (link)

Earlier this month the government of Kerala hosted a dialogue on the COVID-19 crisis involving extensive discussions with Noam Chomsky Amartya Sen, and Dr. Soumya Swaminathan, Chief Scientist of the World Health Organization. V.K. Ramachandran, vice-chairman of the Kerala State Planning Board, conducted fascinating conversations with Chomsky and Sen, and distinguished journalist N. Ram conducted an excellent conversation with Dr. Swaminathan. Links to the dialogues are provided below, and they are all worth viewing. A very good summary of the dialogues is provided in The Hindu here.

Here are a few highlights. Dr. Swaminathan provides a clear, scientifically precise summary of current knowledge about the virus and the best advice available for public health measures to contain its spread. Chomsky points out the connections he sees between the ideological and material commitments of neoliberal governments to corporate profits and their failure to respond adequately to the crisis. The United States government’s actions during this crisis are especially egregious — virtually no effective national policy, on the one hand, and a rush to loosen a raft of environmental regulations during the crisis, on the other. Chomsky underlines the magnifying effects that racial and economic inequalities have had on the distribution of cases and deaths across the population in the United States. He reminds viewers that, terrible as the immediate consequences of the COVID crisis are, the effects of global climate change will be immeasurably worse. Amartya Sen applauds the Kerala government’s consistent attention to the immediate welfare and nutrition crisis threatened by the COVID pandemic, and notes how crucial it is for government policy to be attuned to hunger and entitlement shortfall for vulnerable populations. In this respect the COVID crisis has a lot in common with the Bengal famine of 1943, when a sudden collapse of entitlements for poor people led to massive deprivation and eventually starvation (Poverty and Famines: An Essay on Entitlement and Deprivation).

Sen and Chomsky have devoted their careers to offering analysis and critique of government policy, and it is very interesting to see how they both respond to the largest public health crisis that we have seen in a century. What is especially important from the Kerala experience, it seems, is that the policy values that a government implements have enormous consequences for the wellbeing, health, and safety of the populations that they serve (or fail to serve). Chomsky’s basic view of most liberal democracies is that their policy values are chiefly oriented to the needs of big business, and that this leads to huge inequalities in normal times and in pandemic crisis. Sen has made the case throughout his career that governments should choose policies based on their impact on broad social welfare, not GDP or the stock market. And Kerala presents a fantastic test case: the LDF is a government that is distinctly not beholden to large corporations, it is committed to the welfare of the broad population, and its policies have been highly successful during this crisis in ways that benefit the whole of Kerala society.

Here are the videos.

The Kerala Dialogue on Covid-19

1. Introduction and excerpts from Swaminathan, Chomsky, Sen conversations
https://www.youtube.com/watch?v=JK3HqHvhJk4&t=180s

2. First conversation
N. Ram interviews Dr Soumya Swaminathan, Chief Scientist of the World Health Organization.
https://www.youtube.com/watch?v=YwFGgrHYF4w

3. Second conversation
Dr V K Ramachandran interviews Professor Noam Chomsky, laureate professor of linguistics at the University of Arizona.
https://www.youtube.com/watch?v=fgQKOUqwAZU

4. Third conversation
Dr V K Ramachandran interviews Professor Amartya Sen, Thomas W. Lamont University Professor of Economics and Philosophy, at Harvard University.
https://www.youtube.com/watch?v=ynrTz-aYcfs

Professor V. K. Ramachadran, the vice-chairman of the Kerala State Planning Board, conducted the interviews with Chomsky and Sen. His work as a development economist at the Indian Statistical Institute in Bangalore is discussed herehere, and here.

N. Ram, a distinguished journalist whose work is discussed here, conducts the interview with Dr Soumya Swaminathan, Chief Scientist of the World Health Organization. 

ABM models for the COVID-19 pandemic

In an earlier post I mentioned that agent-based models provide a substantially different way of approaching the problem of pandemic modeling. ABM models are generative simulations of processes that work incrementally through the behavior of discrete agents; so modeling an epidemic using this approach is a natural application.

In an important recent research effort Gianluca Manzo and Arnout van de Rijt have undertaken to provide an empirically calibrated ABM model of the pandemic in France that pays attention to the properties of the social networks that are found in France. They note that traditional approaches to the modeling of epidemic diseases often work on the basis of average population statistics. (The draft paper is posted on ArXiv; link; they have updated the manuscript since posting). They note, however, that diseases travel through social networks, and individuals within a society differ substantially in terms of the number of contacts they have in a typical day or week. This implies intuitively that the transmission of a disease through a population should be expected to be influenced by the social networks found within that population and the variations that exist across individuals in terms of the number of social contacts that they have in a given time period. Manzo and van de Rijt believe that this feature of disease-spread through a community is crucial to consider when attempting to model the progression of the disease. But more importantly, they believe that consideration of contact variation across a population suggests public health strategies that might be successful in reducing the spread of a disease at lower social and public cost.

Manzo offers a general framework for this approach in “Complex Social Networks are Missing in the Dominant COVID-19 Epidemic Models,” published last month in Sociologica (link). Here is the abstract for this article:

In the COVID-19 crisis, compartmental models have been largely used to predict the macroscopic dynamics of infections and deaths and to assess different non-pharmaceutical interventions aimed to contain the microscopic dynamics of person-to-person contagions. Evidence shows that the predictions of these models are affected by high levels of uncertainty. However, the link between predictions and interventions is rarely questioned and a critical scrutiny of the dependency of interventions on model assumptions is missing in public debate. In this article, I have examined the building blocks of compartmental epidemic models so influential in the current crisis. A close look suggests that these models can only lead to one type of intervention, i.e., interventions that indifferently concern large subsets of the population or even the overall population. This is because they look at virus diffusion without modelling the topology of social interactions. Therefore, they cannot assess any targeted interventions that could surgically isolate specific individuals and/or cutting particular person-to-person transmission paths. If complex social networks are seriously considered, more sophisticated interventions can be explored that apply to specific categories or sets of individuals with expected collective benefits. In the last section of the article, I sketch a research agenda to promote a new generation of network-driven epidemic models. (31)

Manzo’s central concern about what he calls compartmental models (SIR models) is that “the variants of SIR models used in the current crisis context address virus diffusion without modelling the topology of social interactions realistically” (33).

 Manzo offers an interesting illustration of why a generic SIR model has trouble reproducing the dynamics of an epidemic of infectious disease by comparing this situation to the problem of traffic congestion:

It is as if we pretended realistically to model car flows at a country level, and potentially associated traffic jams, without also modelling the networks of streets, routes, and freeways. Could this type of models go beyond recommendations advising everyone not to use the car or allowing only specific fractions of the population to take the route at specific times and days? I suspect they could not. One may also anticipate that many drivers would be highly dissatisfied with such generic and undifferentiated instructions. SIR models currently in use put each of us in a similar situation. The lack of route infrastructure within my fictive traffic model corresponds to the absence of the structure of social interactions with dominant SIR models. (42)

The key innovation in the models constructed by Manzo and van de Rijt is the use of detailed data on contact patterns in France. They make highly pertinent use of a study of close-range contacts that was done in France in 2012 and published in 2015 (Béraud et al link). This study allows for estimation of the frequency of contacts possessed by French adults and children and the extensive variation that exists across individuals. Here is a graph illustrating the dispersion that exists in number of contacts for individuals in the study:

This graph demonstrates the very wide variance that exists among individuals when it comes to “number of contacts”; and this variation in turn is highly relevant to the spread of an infectious disease.

Manzo and van de Rijt make use of the data provided in this COMES-F study to empirically calibrate their agent-based model of the diffusion of the disease, and to estimate the effects of several different strategies designed to slow down the spread of the disease following relaxation of extreme social distancing measures.

The most important takeaway from this article is the strategy that it suggests for managing the reopening of social interaction after the peak of the epidemic. Key to transmission is frequency of close contact, and these models show that a small number of individuals have disproportionate effect on the spread of an infectious disease because of the high number of contacts they have. Manzo and van de Rijt ask the hypothetical question: are there strategies for management of an epidemic that could be designed by selecting a relatively small number of individuals for immunization? (Immunization might take the form of an effective but scarce vaccine, or it might take the form of testing, isolation, and intensive contact tracing.) But how would it be possible to identify the “high contact” individuals? M&R consider two strategies and then represent these strategies within their base model of the epidemic. Both strategies show dramatic improvement in the number of infected individuals over time. The baseline strategy “NO-TARGET” is one in which a certain number of individuals are chosen at random for immunization, and then the process of infection plays out. The “CONTACT-TARGET” strategy is designed to select the same number of individuals for immunization, but using a process that makes it more likely that the selected individuals will have higher-than-average contacts. The way this is done is to select a random group of individuals from the population and then ask those individuals to nominate one of their contacts for immunization. It is demonstrable that this procedure will arrive at a group of individuals for immunization who have higher-than-average numbers of contacts. The third strategy, HUB-TARGET, involves selecting the same number of individuals for treatment from occupations that have high levels of contacts.

The simulation is run multiple times for each of the three treatment strategies, using four different “budgets” that determine the number of individuals to be treated on each scenario. The results are presented here, and they are dramatic. Both contact-sensitive strategies of treatment result in substantial reduction in the total number of individuals infect over the course of 50, 100, and 150 days. And this  in turn translates into substantial reduction of the number of ICU beds required on each strategy.

Here is how Manzo and van de Rijt summarize their findings:

As countries exit the Covid-19 lockdown many have limited capacity to prevent flare-ups of the coronavirus. With medical, technological, and financial resources to prevent infection of only a fraction of its population, which individuals should countries target for testing and tracking? Together, our results suggest that targeting individuals characterized by high frequencies of short-range contacts dramatically improves the effectiveness of interventions. An additional known advantage of targeting hubs with medical testing specifically is that they serve as an early-warning device that can detect impending or unfolding outbreaks (Christakis & Fowler 2010; Kitsak et al. 2010).

This conclusion is reached by moving away from the standard compartmental models that rely on random mixing assumptions toward a network-based modeling framework that can accommodate person-to-person differences in infection risks stemming from differential connectedness. The framework allows us to model rather than average out the high variability of close-contact frequencies across individuals observed in contact survey data. Simulation results show that consideration of realistic close-contact distributions with high skew strongly impacts the expected impact of targeted versus general interventions, in favor of the former.

If these simulation results are indeed descriptive of the corresponding dynamics of spread of this disease through a population of socially connected people, then the research seems to provide an important hint about how public health authorities can effectively manage disease spread in a post-COVID without recourse to the complete shut-down of economic and social life that was necessary in the first half of 2020 in many parts of the world.

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Here is a very interesting set of simulations by Grant Sanderson of the spread of infectious disease on YouTube (link). The video is presented with truly fantastic graphics allowing sophisticated visualization of the dynamics of the disease under different population assumptions. Sanderson doesn’t explain the nature of the simulation, but it appears to be an agent-based model with parameters representing probability of infection through proximity. It is very interesting to look at this simulation through the eyes of the Manzo-van de Rijt critique: this model ignores exactly the factor that Manzo and van de Rijt take to be crucial — differences across agents in number of contacts and the networks and hubs through which agents interact. This is reflected in the fact that every agent is moving randomly across space and every agent has the same average probability of passing on infection to those he/she encounters.

Right-wing extremism and the covid-19 crisis

No one needs to be brought up to date on the devastation already wrought by Covid-19, in the United States, in Europe, and in other parts of the world, and more is almost certain to come in the next two years. The virus is highly contagious in social settings — not as contagious as measles, but more so than other viral diseases. It has a high mortality rate for older individuals, but it kills patients of every age. It can be spread by persons who do not yet show symptoms — perhaps even by people who will never develop symptoms. The disease has the great potential of overwhelming health systems in regions where it strikes hardest — northern Italy, New York City, Britain, Detroit. There is no effective treatment for severe cases of the disease, and there is no vaccine currently available. This is the pandemic that sane governments have feared and prepared for, for many years. Ali Khan, an experienced and long-serving leader on infectious disease at the Centers for Disease Control and Prevention, provides vivid descriptions of the background scientific and public health infrastructure needed to contain viral outbreaks like ebola, monkeypox, MERS, and SARS (The Next Pandemic: On the Front Lines Against Humankind’s Gravest Dangers). (Here is a list of possible global virus threats by the World Health Organization (link).

It is therefore plain to any sensible person that government-enforced public health measures are required in order to slow the spread of this disease. Countries that were slow to take the pandemic seriously and establish strong measures designed to slow the infection rate — like the United States and Great Britain — have reaped the whirlwind; the United States now has the highest number of Covid-19 cases in the world (link). And the stakes are incredibly high. The 1918 Spanish flu, for example, hit the city of Philadelphia with savage effect because the mayor decided not to cancel the Liberty Loan parade on September 28, 1918 (link); whereas cities like St. Louis made different decisions about public gatherings and had much lower levels of influenza.

The governors of most states in the United States have enacted physical distancing orders mandating “stay-at-home” requirements, business closures, closures of public places, and restrictions on public gatherings. And these measures have worked, on the whole. The governor of Michigan, my home state, for example, has assembled a world-class team of scientific and health advisers concerning the details of the shut-down orders, and a highly respected committee of business and health system leaders to work on developing a strategy for reopening the state in a way that does the best job possible of protecting the health of our ten million citizens. And the curve has flattened.

But now we come to the right-wing protests that have occurred in Lansing and other state capitals around the country (linklink). Guns, extremist placards, threatening behavior, and an armed invasion of the floor of the Michigan state house — what in the world is going on here? Protest of government policy is one of the fundamental rights of citizenship — of course. But why heavily armed protesters? Why racist, white-supremacist groups in the crowd? Why the hateful, vitriolic language towards elected officials? What are the underlying political motivations — and organizational resources — of these protests?

Cas Mudde has a perceptive analysis in the Guardian (link). His recent book The Far Right Today provides the broader context. Mudde sees the anti-lockdown demonstrations as being largely about Donald Trump’s increasingly desperate efforts to win reelection. Mudde calls out the financial ties that exist between these demonstrations and well-funded not-for-profit Republican organizations linked to Betsy DeVos (link).

And indeed, these protests look a lot like Trump campaign rallies, calling the faithful in “battleground” states. The hats, slogans, and behavior make it clear that these protesters are making a political statement in favor of their president. And the president has returned the compliment, describing these protests as reasonable, and encouraging more. The president’s behavior is, as usual, horrible. The idea that the president of the United States is actively seeking to interfere with the performance of the governors of many states in their duties of preserving the health and safety of their citizens, after himself failing abysmally to prepare or respond to the pandemic, is something out of a dystopian novel. Here is how Mudde describes the political strategy underlying this approach:

For Trump, the anti-lockdown protests provide him with visible popular support for his Covid-19 strategy. For the sake of his re-election, he is keen to move discussion from public health to the economy. Given that a clear majority of Americans support the stay-at-home policies, Trump needs the momentum to shift. The protests can help him, by taking his struggle from the White House to the streets, and thereby to the media. (link)

Where does the gun-toting extremism come into this political activism? One obvious strand of this “movement” is the extremist anti-government ideology that brought world attention to the Malheur National Wildlife Refuge takeover in 2016. These are radical militia adherents, rejecting the authority of the Federal government in all of its actions, and willing to overtly threaten the lives of others in their activism. Brandishing semi-automatic weapons is not political theatre; it is not “simply an assertion of second amendment rights”; it is a deliberate effort to intimidate and frighten the rest of society. And it is hard to avoid the question — what if these were anarchist protesters in black masks carrying semi-automatic weapons? Or Black Panthers? And what if the venue were the entrance to the White House, or the entrance to the Capitol Building in Washington? How would conservative Republicans react to these scenarios?

Another stream, not entirely distinct from the first, is the persistent and growing white supremacist movement in the right wing of conservative politics. Their involvement in these protests is opportunistic, but their potentially violent opposition to democratically elected government is in common. Here is a report by the Southern Poverty Law Center about involvement by extremist nationalist group the Proud Boys in the anti-lockdown demonstrations; link. Here is a snippet from the SPLC report:

Even though the Proud Boys weren’t behind efforts to get the protests off the ground, they quickly realized their value. They are the perfect platform for the proto-fascist group to make the case that the will of a small minority of Americans – the hyper-individualistic “patriots” who attend these rallies – should supersede democratic processes, and that individual desires should trump the collective public good. The protests also provide other benefits: the chance to launch their ideas into wider right-wing circles, further cement their status as core members of the Trump coalition, build relationships with local politicians and gain attention from outlets like Fox News.

(Neil MacFarquhar and Adam Goldman’s coverage in the New York Times of the white-supremacist terrorist organization, the Base, is sobering reading; link.)

It is certainly true that the pandemic is creating huge economic suffering for millions of Americans (and Europeans, Indians, Brazilians, …). People are suffering, and some much more than others. Poor people, hourly workers, small farmers, gig workers, and people of color are disproportionately victims to the economic recession, and people of color are vastly over-represented among the infected population and the death rolls of the disease. Closures of businesses have led to vast numbers of unemployed men and women. But notably, these demonstrations in Lansing and elsewhere don’t seem to be supported by the constituencies most at risk in the economic shutdown; the participants who show up to flaunt their guns and their reckless disregard for social distancing seem to be mostly angry activists pursuing their own agendas.

So an answer to the fundamental question here — why are we seeing this surge of right-wing extremist protests to pandemic policies? — seems to involve three related factors: political supporters of Donald Trump (President Trump’s efforts to normalize the pandemic and attack Democratic governors who are doing something about it); anti-government extremists who object to any exercise of the appropriate powers of the state; and opportunistic efforts by white supremacist organizations to capture the moment. Add to that the understandable concerns that citizens have about their immediate economic futures, and you have a combustible mixture. And the issue of trust in the institutions of government, raised in a recent post, is plainly relevant here as well; these extremist organizations are working very hard to undermine the trust that ordinary citizens have in the intentions, competence, and legitimacy of their elected officials.

Yes, the economic consequences of the pandemic are enormous. But the alternative is undoubtedly worse. Do nothing about physical distancing and the virus will sweep every state, every county, and every town. Experts believe that the unchecked virus would infect 20-60% of the globe’s population. And a conservative estimate of the mortality rate associated with the disease is on the order of 1%. Thomas Tsai, Benjamin Jacobson, and Ashish Jha do the math in Health Affairs (link), assuming a 40% infection rate. For the United States that implies an infected population within about eighteen months of about 98.9 million victims, 20.6 million hospitalizations, and 4.4 million patients needing treatment in ICUs. Both hospitalization rates and ICU demand greatly exceed the total stock available in the United States. Tsai et al do not provide a mortality estimate, but at a 1% mortality rate, this would amount to about a million deaths. It goes without saying that the health system, the food supply system, and virtually every aspect of our “normal” economy would collapse. So the only choice we have is rigorous physical distancing, a sound public health plan for cautiously restarting economic activity, massive increase in testing capacity, aggressive search for treatments and vaccine, and generous programs of Federal assistance to help our whole population make it through the hard times that are coming. And generosity needs to come from all of us — contributions to local funds for food and social assistance can make a big difference.

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