I need you to read this and decide about Coronavirus

Approaching the pandemic with a systems-thinking lens

Phoebe Tickell


This article is aimed at CEOs, people who run organisations, events, conferences, communities, or have any sway over the decision-making at these places. I need you to read these selected articles, or the summaries I provide, and use this as a briefing document to decide about what to do to respond adequately to coronavirus, and the shape of that response.

Who am I? I am a concerned citizen, an ex-microbiologist who used to do research on bacteria and genetics, and someone who has practised systems thinking for 10 years. I am not a doctor, epidemiologist or health expert. But this is how I’ve been making sense of the virus and what to do, and I hope it can help others facing the same moral dilemmas, or feeling panic and confusion about what is the best course of action.

Situation right now

Currently, in the UK, everything seems calm, and life is going on as “business-as-usual”. No schools have closed, transport and travel is continuing as usual, some people are cancelling their holidays and conferences have started to be postponed. But everyday life feels pretty much exactly the same — there are some amusing jokes about the toilet paper running out (wink wink) and a bit of panic buying here and there — but easily dismissed as overzealous preppers getting ready for an imagined apocalypse.

Everyone is talking about coronavirus, but I have witnessed mixed behaviours when it comes to the sense-making of what to do and what it means: different levels of cognitive blocking resulting in patchy preparation and incomplete decision-making, i.e. decision-making without having full cognitive awareness of the facts, the predictions, and the ability to balance the risk to take appropriate action.

People are looking at what is happening in other countries and doing a sort of ‘distancing’: i.e. thinking “that might be happening there but it’s not going to happen here”. This article pulls together some of the data and information coming out to help you make an informed decision about the future, given different scenarios and choices of action.

Don’t panic, take responsible action

The last thing I want to do is panic people. Instead, I want to present some pieces of data, opinion and perspective I have found useful in my sense-making and decision-making around precautions, the attitude I am approaching this situation with, the advice I am giving and the places I can exercise my responsibility and leadership.

My hope is that you can then use these in order to make a well-informed decision from a place of responsibility and care to not just yourself and those in your immediate circle of care, but also those who may be invisible to you and most susceptible to the virus, to not getting adequate care, or to not being able to cope in the event of an infection.

The tone and care with which we respond to this, matters

This is when systems thinking gets real and out of the boardroom — when your perception of interdependency in real-time will lead to very different systemic effects, with people’s lives on the line. My friend and fellow systems thinker Nora Bateson writes and speaks about the tone of responding to systems change. This is important now.

All of the practice you may have done around systems thinking, community care, holding complexity, is coming to bear right now. This virus is forcing us to see in systems. Because it doesn’t matter if you’ve got yourself prepared with your supply of hand sanitizer and food stockpiles for 2–3 weeks. The truth is, if you’re under 60 and in relatively good health, the chances of death or severe complication are low.

But it matters to everyone if this thing spreads uncontrollably and overwhelms our healthcare system. It matters to everyone if hospitals have to choose who to save and who to leave to die. It matters to everyone if our society has to go into shutdown for months on end.

We are interdependent, and everyone has someone they care about, and that person has someone else they care about. And in a complex situation like this one, we need to think on a systemic level, take systems-aware precautions, and be aware that the consequences of our actions will have systemic effects. We’re already seeing massive systems change in motion. Schools are shutting down. What will be the effect of that on families? What will be the effect of that on children’s diets? In New York, if schools shut down, they risk denying 750,000 children and 114,000 homeless children meals, who rely on school for hot food, medical care and even laundry. What will happen to those families? Who will take care of those kids?

The potential impacts and changes caused by this virus are huge. We cannot tell what the ripple effects of this virus will be, but we have a responsibility to help curtail it before it’s too late and massive, irreversible systems change happens, that noone was prepared to deal with.

As I’ve said on Twitter:

In all of this, consider others, and not just yourself. Consider this perspective, from Jason Hine:

People who say: “The coronavirus is nothing significant”, or: “it’s just something we have manifested”, or: “it’s only media hysteria”, or “it’s a conspiracy, someone is behind it”, or: “it might effect some people but it doesn’t matter to me”, are displaying their rank and privilege, to do what they want with a callous disregard for those older people who are at most risk from the virus.

People who say: or “I’ll just keep travelling anyway”, or: “only hysterical or stupid people will take precautions” or: “I’ll just carry on and do whatever I want” are displaying their disregard for those who are physically weaker, older or infirm. Rank and privilege effects the psyche in such a way that, the more we have of it, the harder it is to emphasise with other people, unless awareness is brought to that rank.

Yes hysteria and panic are not helpful to anyone. And also: all these superfit or spiritual or well-resourced people, who think it will be ok for them and there is no need to take the issue seriously are displaying their callous disregard for those physically weaker than themselves. Ableist and age discriminating rank shrinks the brain’s capacity for compassion and co-feeling unless people actually wake up to it”

Ok, so what do I need to know?

(adapted from Coronavirus: Why You Must Act Now):

The coronavirus is coming to you.
It’s coming at an exponential speed: gradually, and then suddenly.
It’s a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Sick people will be turned away because of a shortage of beds.
Doctors will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.

That means cancelling events, cancelling conferences, sending people who can to work from home.

As a politician, community leader or business leader, you have the power and the responsibility to prevent this.

You might have fears today: What if I overreact? Will people laugh at me? Will they be angry at me? Will I look stupid? Won’t it be better to wait for others to take steps first? Will I hurt the economy too much?

But in 2–4 weeks, when countries are in lockdown, when the few precious days of social distancing you will have enabled will have saved lives, people won’t criticize you anymore: They will thank you for making the right decision.

Ok, now let’s get into the data.

This is not the flu #1 — fatality rate

This is not just the flu. Flu has a death rate of 0.1%. The World Health Organisation quotes 3.4% as the fatality rate.

Below is the graph plotting data from the Chinese Center for Disease Control and Prevention, and showing death rate for different age brackets. In people aged 50–59, coronavirus is 13x more deadly than the flu. In people over 80 years old, coronavirus is estimated 148x more deadly than the flu. In people who have weak immune systems, the rate is also higher. We can also be sure that these figures are an underestimate, because of the underestimation of how many people contracted the flu and recovered.

In the countries where the spread of the virus is most advanced, we still don’t have conclusive evidence. In China, more than half of all diagnosed patients in China have now been cured, but it still remains to be seen how many of the remaining patients survive. In South Korea, of the 7,478 confirmed cases, only 118 have recovered; the low death rate may yet rise.

Meanwhile, the news from Italy, a country with a highly developed medical system, has so far been shockingly bad. In the affluent region of Lombardy, for example, there have been 7,375 confirmed cases of the virus as of Sunday. Of these patients, 622 had recovered, 366 had died, and the majority were still sick. Even under the highly implausible assumption that all of the still-sick make a full recovery, this suggests a case fatality rate of 5 percent — significantly higher, not lower, than in China.

This is not the flu #2 — severity of symptoms

An estimated 15–20% of infected individuals suffer from severe symptoms that require medical attention, including pneumonia with shortness of breath and lowered blood oxygen saturation.

Symptoms take delayed time to show up

Symptoms take roughly 2–14 days to show up. The virus spreads before people show symptoms. It is very difficult to predict how many people are actually infected at any given time, giving skewed statistics. Therefore you could very well have the virus and still feel fine, and therefore still think it’s fine to move around, take public transport, go to crowded places.

This virus is highly contagious

With an estimated R0 between 1.4–6.49 (i.e. the number of people a sick person is likely to infect) and a mean estimate of 3.28, SARS-CoV-2 is much more infectious and spreads much faster than the seasonal flu, which has a median R0 of 1.28.

And the virus seems to be most infectious early on (when no symptoms)

New preliminary research, posted Sunday (March 8) to the preprint database medRxiv shows that people seem to shed large quantities of the virus early in their illness and likely become less infectious as the disease wears on. This may hint at why the new virus spreads so easily: many people may be at their most infectious when exhibiting only mild, cold-like symptoms, or none at all. The research has not yet been peer-reviewed and only has 9 study participants, but corroborates with other observations.

We are underestimating the number of people infected

Given the above, this should make sense. But adding to this, factors of human delay, such as — a country not being equipped for testing, not putting adequate testing/detection measures in place, withholding information for worry of political or economic implications… And you have a situation of ‘systems delay’. The same way as when you view the sun, you are seeing light that is actually from 8 minutes in the past, the information we have at any current moment of coronavirus is most likely arriving from days in the past.

The virus spreads in an exponential fashion

Don’t be fooled by low numbers at the start of the curve. The nature of exponential growth is this:

  • Would you prefer £500 now?
  • Or would you prefer £1 now but I promise to double it every day for 2 weeks.

The trick of this question is that it’s easy to think that the £500 straight up is a better deal. However if you take £1 and double it each day for 2 weeks, or 14 times, you get the following: 1 + 2 + 4 + 8 + 16 + 32 + 64 + 128 + 256 +512+1024+2048+4096+8192 = £16383.

The human mind finds exponential growth difficult to grasp. This flu is spreading exponentially. It can seem a million miles away on day 1, but suddenly and rapidly very close and spreading fast.

The doubling rate is important here. It makes a difference how steep the curve is depending on how many days it takes to get from 1 to 2 and 2 to 4. The average doubling time for the coronavirus is 6.2 days. So if we are at 500 cases now, in 2 weeks we will likely be past 2000 cases.

The UK is at the beginning of the exponential curve

When referencing Italy, a common response has been “oh but that’s just the worst example”. Currently at the time of writing, there are only 456 confirmed cases of Coronavirus in the UK. Italy, a relatively similar sized country was in the same position just 3 weeks ago.

Italy had 62 identified cases of COVID-19 on the 22nd of February. It had 888 cases by the 29th of February, and 4,636 by the 6th of March. Today, Italy has 10,149 cases of the coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air.

My friend plotted this graph showing the confirmed cases per country at the point of 100 cases being reported. This is on a logarithmic scale which means that a straight line represents an exponential curve:

Graph created by Richard D. Bartlett

If we do not take preventative action, you can see that the UK is roughly on the same trajectory as the US, which has just shot up in the number of cases to match a similar number to South Korea. Which is just below the same figure 2 weeks ago in China. Now you see what I’m saying?

Countries that prepare can reduce deaths by ten

From studying existing countries and their responses / death rates, we can see the difference in what the number of cases and deaths looks like in a country that responds quickly and with extreme measures compared to those who don’t. From Coronavirus: Why You Must Act Now:

  • Countries that are prepared will see a fatality rate of ~0.5% (South Korea) to 0.9% (rest of China).
  • Countries that are overwhelmed will have a fatality rate between ~3%-5%

Therefore, countries that are able to act fast can contain the virus significantly and reduce the number of deaths by ten (compare 0.5% to 5%).

China took extreme measures to contain the virus, and you can see the impact here: the beginning of the curves of the Chinese regions show an exponential rate (the beginning of a ‘hockey stick’ graph) and then flatten out to be contained under 2000 total cases. Many western countries have already overtaken China (the US is thought to have 10s of 1000s of cases already).

Social distancing will save our healthcare from collapsing

The final important piece of data is that so far only one measure has been effective against the coronavirus: extreme social distancing.

Before China canceled all public gatherings, asked most citizens to self-quarantine, and sealed off the most heavily affected region, the virus was spreading in an exponential fashion. Once the government imposed social distancing, the number of new cases levelled off; now, at least according to official statistics, every day brings more news of existing patients who are healed than of patients who are newly infected.

Here is a curve showing what that means in graphic form:

A few other countries have taken proactive steps to increase social distancing before the epidemic reached devastating proportions. In Singapore, for example, the government quickly canceled public events and installed medical stations to measure the body temperature of passersby while private companies handed out free hand sanitizer. As a result, the number of cases has grown much more slowly than in nearby countries (see the pink line bottoming out at the bottom of the exponential curve above).

If you are in a position of power, you can act now

The coronavirus could spread with frightening rapidity, overburdening our health-care system and claiming lives, until we adopt serious forms of social distancing.

This suggests that anyone in a position of power or authority, instead of downplaying the dangers of the coronavirus, should ask people to stay away from public places, cancel big gatherings, and restrict most forms of nonessential travel.

As well as social distancing, we will need other measures

Most forms of social distancing will be useless if sick people cannot get treated — or afford to stay away from work when they are sick. Therefore at the same time as large scale closures and cancellations, the government should also take some additional steps to improve public health. It should take on the costs of medical treatment for the coronavirus, grant paid sick leave to stricken workers, promise not to deport undocumented immigrants who seek medical help, and invest in a rapid expansion of intensive care facilities.

This could also be a great opportunity to test and trial social practices and approaches which could make perfect sense both in and out of a pandemic, for example:

Or learn from other countries, who are using systems thinking to create solutions that work indirectly but with large downstream effects:

(H/T to Alistair Parvin for sharing this via Twitter). By suspending mortgage payments, Italy is taking off the burden from people who feel unable to take time off work to stay at home. Among other well-placed interventions, this shows an awareness that the reason many (not all) people need to go to work is to make a salary to pay for rent or pay off a mortgage.

In Italy (9 days ahead), doctors are having to decide who is worth saving

In Italy, which is a projected 9 days ahead of us, there are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody .The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow in the extraordinary circumstances they are facing.

The document begins by likening the moral choices facing Italian doctors to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, its authors suggest, it is becoming necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.”

You can read more about this here: The Extraordinary Decisions Facing Italian Doctors

Taking responsibility: don’t panic, do the right thing

Finally, the most important responsibility falls on each of us. It’s hard to change our own behaviour while the government and the leaders of other important institutions send the social cue that we should go on as normal. But we must change our behaviour anyway. If you feel even a little sick, for the love of your neighbour and everyone’s elderly relatives, do not get on a plane, do not go to work, do not go shopping — if you can avoid it, avoid it.

Looking to lessons from history: the Spanish Flu

The influenza epidemic of 1918 infected a quarter of the U.S. population, killing tens of millions of people. Seemingly small choices made the difference between life and death.

As the disease was spreading, Wilmer Krusen, Philadelphia’s health commissioner, allowed a huge parade to take place on September 28; some 200,000 people marched. In the following days and weeks, the bodies piled up in the city’s morgues. By the end of the season, 12,000 residents had died.

In St. Louis, a public-health commissioner named Max Starkloff decided to shut the city down. Ignoring the objections of influential businessmen, he closed the city’s schools, bars, cinemas, and sporting events. Thanks to his bold and unpopular actions, the per capita fatality rate in St. Louis was half that of Philadelphia. (In total, roughly 1,700 people died from influenza in St Louis.)

Look at Max Starkloff. Be more like Starkloff.

(Reference for this from article ‘Cancel Everything’)

A simulation that helps decide when to shut your office

Tomas Pueyo has created a model (direct link to copy). that you can input your metrics into and define a percentage risk you are wiling to take, and find out whether it’s time to shut your office yet or not. It enables you to assess the likely number of cases in your area, the probability that your employees are already infected, how that evolves over time, and how that should tell you whether to remain open.

Input the number of employees in your organisation, the number of official cases in your area or city, as well as some other details.

Stay at home if you can: The Self-Quarantine Manifesto

Taken directly from the https://staythefuckhome.com/ campaign:

  1. Don’t panic, but be alert.
  2. Wash your hands often and practice good cough and sneeze etiquette.
  3. Try to touch your face as little as possible, including your mouth, nose, and eyes.
  4. Practice social distancing, no hugs and kisses, no handshakes, no high fives. If you must, use safer alternatives.
  5. Do not attend concerts, stage plays, sporting events, or any other mass entertainment events.
  6. Refrain from visiting museums, exhibitions, movie theaters, night clubs, and other entertainment venues.
  7. Stay away from social gatherings and events, like club meetings, religious services, and private parties.
  8. Reduce your amount of travel to a minimum. Don’t travel long distances if not absolutely necessary.
  9. Do not use public transportation if not absolutely necessary.
  10. If you can work from home, work from home. Urge your employer to allow remote work if needed.
  11. Replace as many social interactions with remote alternatives like phone calls or video chat.
  12. Do not leave your home if not absolutely necessary.

And don’t forget: this is a time to take care of each other

In a state of panic, it’s easy to get myopic and shutdown. Studies have shown the link between stress, anxiety and egocentrism. How do we stay open enough to read the news, to take in the necessary information, without shutting down in a panic or locking out other people from our consideration?

We need to stay alert, and stay active and caring, and avoid shutting down. In states of panic or stress, we can go into states of numbing, and at a time when we need to show up for each other more than ever, this could be disastrous. Joanna Macy’s Work That Reconnects is a body of work made for times like these, which help face emotions like grief, shock, confusion, panic, anger, and fear, in a way that doesn’t lead to numbing or dissociation. From this place people are able to be fully alive in their senses and take in the important information necessary to make balanced decisions and responsible action on behalf of their life, and others.

If you are shocked or stressed after reading this article, you may want to try this Breathing Through exercise to help remind you of your body’s self-organising capability to make sense of and process distressing or difficult information. If you are interested in learning more about this work, please get in touch and I will gladly share more.

Do not lose heart. We were made for times like these.

You can decide.

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Phoebe Tickell — Catalyzing transformative innovation in the face of converging crises, advising on complexity approaches, systems design, regenerative leadership, and education for regenerative development.


Coronavirus (COVID-19): Update and Thorough Guidance

Coronavirus: Why You Must Act Now

Cancel Everything

A Movement to Stop the COVID-10 Pandemic — #StayTheFuckHome

Coronavirus in N.Y.C.: Why Closing Public Schools Is a ‘Last Resort’

The Extraordinary Decisions Facing Italian Doctors

Severe influenza pandemic in Macaronesian Islands: Preparedness and Response — Lucas Gonz.lez Santa Cruz, December 15, 2011




Phoebe Tickell

Cares about the common good. Building capacity for deep systems change. Complexity & ecosystems obsessive. Experiments for everything. 10 yrs #systemsthinking.