Coronavirus: Strategy and tactics to combat the pandemic

One can easily understand the aim of strategic planning, but the importance of tactics is frequently overlooked.

An MDA medic wearing protective gear against coronavirus waits outside Shaare Zedek Hospital, Jerusalem (photo credit: MARC ISRAEL SELLEM)
An MDA medic wearing protective gear against coronavirus waits outside Shaare Zedek Hospital, Jerusalem
(photo credit: MARC ISRAEL SELLEM)
Medical matters are complicated and therefore difficult to understand, particularly since they are described in specialist vocabulary.
The principles can be easily explained by a military analogy.
A successful campaign depends on planning by two distinct disciplines: strategy and tactics.
One can easily understand the aim of strategic planning, but the importance of tactics is frequently overlooked. Two examples, one successful and one unsuccessful, make the point.
History shows that Stalin pressured the Western Allies to invade the European mainland in 1942 and 1943. To make Germany fight on two fronts was excellent strategy, but the actual invasion required detailed tactical planning. The Western Allies used operational research in their planning. Operational research can be loosely defined as the use of scientific methods to address practical problems. The result was the successful invasion of Normandy – a strategic and a tactical success.
The battle of Arnhem illustrates what happens when tactical planning is inadequate.
The strategic goal was to invade Germany via the Ruhr, its major industrial area. The aim was to destroy Germany’s manufacturing potential and cripple its war effort so badly that there would be a rapid end to the conflict.  This was a reasonable aim.
The problem was that the paratroopers who held the crucial Arnhem bridge had to be relieved within 48 hours by Horrock’s XXX Corps. There was only one road for XXX Corps to reach Arnhem and the terrain on either side of it could not hold armour. If that road was to be blocked early, as it was, the paratroopers could not be relieved in time. That, together with other tactical mistakes, doomed the operation.
What has this to do with the coronavirus pandemic?
The strategic planning is logical and one hopes “accurate.” Tactical planning is non-existent.
Why? Tactical planning depends on information – intelligence, in military terms. The information is there but nobody has attempted to gather it.
There is also a problem for the future. The economists tell us that we are heading toward a severe depression. Economic depression initiates social deprivation, social deprivation increases morbidity, and morbidity leads to deaths. Unlike corona, deaths in this case will not be mainly among the elderly. Children will be included. And Naftali Bennett, Israel’s defense minister, is right to worry about a rise in suicides.
A lesson from the past
I became a general practitioner as the junior partner in my father’s practice on October 1, 1957. Within two weeks we were managing an influenza epidemic. The virus targeted older people, most of whom had pre-existing serious conditions. Although the virus produced mild symptoms in the younger age group it was described, in the press, as a killer. There was a whiff of racism in the published reports which terrorized the community. These “yellow slant-eyed” viruses were committing mayhem.
Sixty-three years later, I can see the identical phenomenon in Israel with that nasty Chinese virus, COVID-19, instead of Asian influenza.
I saw a number of such epidemics during the 35 years I worked in the city of Dundee in Scotland. The pattern was the same in all of them.
I was responsible for 3,000, plus or minus, people.  The city’s population was 180,000. The city itself is semi-circular in shape. Its diameter (9.6 km) is its southern border, the north bank of a river estuary. An epidemic would start in the east and slowly move from east to west over the course of two weeks. After two weeks it would suddenly become quiet; the epidemic was over.
This does not mean that it would take two weeks in other locations. The timing was presumably determined in part by population density, demographic features of the population, and the size of the city.  One assumes that it would take longer in larger cities and less time in smaller places. Nor would the virus strike simultaneously in all parts of the United Kingdom.
It is not fantasy to suggest that similar patterns could be found internationally, subject to population size and density, and demographic character. Climate, too, may be a factor.
However, other elements, which determine the nature of the current pandemic, did not play a role in these earlier epidemics.
A pandemic is simply an international epidemic and what we have today is not unique.
International travel, thanks to airlines, and the needs of business, trade, and tourism, had enhanced contact between people by orders of magnitude. The result is the rapid spread of infection. One person in a plane can infect scores of fellow passengers, who infect scores in their turn when they arrive at their destination.
A second factor is modern communication. The computer revolution has enabled humanity to spread information at a speed which was formerly impossible. When information is accurate, it is an asset. But information spread this way can be misleading and even wrong. Misleading information can be accidental but there are occasions when it is spread with malicious intention.
So what?
The current pandemic is now history. The aim should be to plan a mechanism to anticipate future epidemics and to create a system both to protect the public and minimize the economic ill effects. This requires forward planning. The current shutdown treats the country as a single unit, but units of this type are the sum total of smaller population units, which comprise the whole. For example, the Galilee or the Negev may have a different pattern to Tel Aviv and Jerusalem as a result of different population densities. Similarly, even within cities, the pattern may vary from neighborhood to neighborhood. The pattern may also be affected by differences in local communities. Social deprivation and morbidity go together and one does not usually find the socially deprived and affluent in the same subcommunities.
Each community is the cumulative result of its individual constituents. Each individual is unique and in turn the result of many variables. The community pattern is the sum of its individuals’ personal characteristics.
Many years ago, before computers, when my research interest was the factors which created the demand for medical attention, one could only get this information by sampling. This is no longer necessary. All general practitioners use computers to record their patients’ records in complete detail. It is now possible to integrate these records to establish morbidity patterns for communities, towns and cities, and regions.
When examining patterns of individual morbidity, one must distinguish between episodes of illness and consultations. While some episodes, like cancers, may be long-term, others have a clear beginning and end. Upper respiratory infections, like corona, are in the latter group. The number of consultations for an episode varies with the gravity of the condition, but is also a result of the patient’s characteristics which determine his/her emotional reactions. The episodes are what is important from an epidemiological point of view.
I counted the number of episodes over the course of a year for each patient in the study. Some had only one or two, others more, and when I asked my statistical adviser to investigate whether there was a pattern to a complex of four or more episodes in the observation year, he found that the accident proneness distribution fitted the picture. This meant that some people had a vulnerability to respiratory, gastro-intestinal, urinary tract illness and so on. The point is that that these people appeared to be reasonably healthy and the pattern was only recognizable when one considered the individual’s medical status over time, rather than dealing with each episode as a discrete event.
General practice computers make ongoing analysis possible. One can accumulate the morbidity pattern of each individual and by pooling these observations establish the number of “those vulnerable” in a community. 
By continuing the process through creating regional pools from the cumulative community patterns, one can map the national morbidity pattern easily in a country like Israel. This should be an ongoing process which will establish a “normal” pattern.
COVID-19 is an upper-respiratory tract infection. Upper-respiratory tract infection is the most common cause of human illness and occurs at a low level throughout the year. A rise in its frequency, together with population density data, could indicate the beginning of an epidemic and, if recognized, immediate action can be taken to limit the scope of the threat.
This need not be labor intensive.  A program can be written to allow the data to “self-monitor” by sounding a warning when a rise occurs. Action should be taken at this alarm.
A facility like this should not be limited to upper respiratory infection. There are other epidemic conditions which can be handled in the same way. The system may also identify unrecognized patterns.
The objective is to recognize the locality of an outbreak at its earliest stage and to take immediate action to prevent its spread. And by tracking the movement of an epidemic it may be possible to avoid the necessity for universal shutdown. The isolation of a few key communities would permit the others to function more normally.  
Financing will be necessary to achieve this, but when one considers the large sums that are spent on relatively uncommon diseases, it would appear to be money well spent.
The writer is a retired Scottish physician who lives in Beersheba