Saturday, March 28, 2020

Covid-19: toilet paper and containment

Two Covid-19 issues have been weighing on my mind: toilet paper hoarding, and virus containment.

Many have been asking why people around the world have been hoarding toilet paper. A friend of mine captured the irrationality of people hoarding toilet paper by saying “It’s because they’re scared shitless!” 

There is a long history of toilet paper shortages during crises; the US had a run on toilet paper in 1973, in part created by a joke told by late night TV host Johnny Carson, but coinciding with shortages of many other consumer items, including gasoline (petrol).

I’m especially intrigued by this run on toilet paper because it seems to have started in Hong Kong, and spread to much of the rest of the world. Hong Kong even had a widely reported case of a toilet paper robbery. There seems to be something cross-cultural about the phenomenon.

Few of the articles on this phenomenon really offer a good explanation (see SCMP Agence France-Presse article). offered a list of explanations on March 9th that included:
  1. Reason 1: People resort to extremes when they hear conflicting messages
  2. Reason 2: Some are reacting to the lack of a clear direction from officials [Hmm, this sounds like Reason 1]
  3. Reason 3: Panic buying begets panic buying [This is true; now that there is a shortage, I have no choice but to try to buy toilet paper. This is the “game theory” explanation. But it does not explain why the panic buying started in the first place.]
  4. Reason 4: It's natural to want to overprepare. [Really? Why focus on toilet paper and not tuna or beans?]
  5. Reason 5: It allows some to feel a sense of control [Control what?! An uncontrolled bowel?!]

So the psychologists say that by preparing when they feel helpless, even just by purchasing toilet paper, people get a sense of control. But none of these reasons explain why “toilet paper” and not, say breakfast cereal. After all, diarrhea is not one of the symptoms of the coronavirus.

This is actually a classic cultural, and thus anthropological, question: why do people value one thing over another. Economists can tell you where supply meets demand, but they assume demand exists. Anthropologists want to know what creates demand for a particular thing, i.e. why it has value.

Here is a better explanation. Niki Edwards, School of Public Health and Social Work, Queensland University of Technology:

Toilet paper symbolises control. We use it to “tidy up” and “clean up”. It deals with a bodily function that is somewhat taboo.

When people hear about the coronavirus, they are afraid of losing control. And toilet paper feels like a way to maintain control over hygiene and cleanliness.

So, to really get at the root of the phenomenon, we need to look at the symbolism of toilet paper. The “control” some people talk about is not controlling the disease, but the control of bodily functions that we usually rather not think about. People think of toilet paper as essential for “hygiene.” People are also told to wash their hands after they go to the bathroom. Thus, toilet paper is associated with hygiene and hand washing.

Indeed, a lot of the “hygiene” people follow to protect themselves against infection is not really effective. During SARS, there were many reports of people cleaning all the door knobs inside the house, even though they were in isolation at home. With no outsiders coming in, it is hardly necessary to wipe door knobs. The same is happening now in the US. I've heard of people washing their hands compulsively even though they are in isolation. And in one business I know of, though there are less than 10 managers left working in a large office, they have cleaning staff come through the office numerous times a day to wipe down and disinfect surfaces. I think the managers would be safer if the cleaning staff did not come, but the idea that surfaces should be “disinfected” and “cleaned” is very powerful.
Containment vs Mitigation

When Americans look at what China did to control the Covid-19 virus, they tend to attribute it to China’s authoritarianism. It is true that there are aspects of China’s response which were possible only because of the authoritarian state—including the denial of the problem for 3 weeks, when doctors knew the virus was serious and spreading (though we still, even today, March 28, have officials in the US downplaying the seriousness of the epidemic). But most of China’s response is not due to the authoritarian nature of the state, but to state capacity. China was able to trace contacts and impose quarantines because it had the health care personnel to do it. Proof that it is not due to authoritarianism is the fact that Korea and Taiwan were also able to react as quickly, but are very robust democracies. In Korea and Taiwan, people who came down with Covid-19 had their contacts traced and notified, and some were put in isolation to prevent them from further spreading the virus. This has helped contain the virus in China, Korea and Taiwan. (For an article on Korea, see here; on Taiwan, see here.) 

The US did not do that. Authorities delayed responding. Already in mid-February, experts were saying that the opportunity to contain the virus in the US was close to finished. (See for example Tom Bollyky of the Council on Foreign Relations, “Expert: It’s close to the point where governments decide thecoronavirus outbreak is a mitigation vs. containment situation”)

In one case, in Westport, CT, on March 5, 50 people at a party were exposed to the virus and dozens subsequently came down sick.   “Even in a well-connected, affluent town like Westport, contact tracing quickly overwhelmed health officials. ... One of the party guests later acknowledged attending an event with 420 other people, he said. The officials gave up.” This is because they lack the capacity, and perhaps the will. The parts of Asia that went through SARS were more aware that contact tracing was important. 

Contrast this with what was done in China. First, everyone who traveled to other parts of China from Wuhan was forced by local authorities to quarantine. Note that this sounds oppressive and authoritarian, but they were able to do something similar in Taiwan and Korea. Then, they closed off neighborhoods with infections, forced visitors to go through 14 days of quarantine before going to work, and placed restrictions on restaurants (but they did stay open, in contrast to ours which are all closed). I highly recommend this 12 minute video (in window below) by a Japanese businessman based in Nanjing, which was not heavily affected by Covid-19, but you can see the efforts the city went through to contain the epidemic. 

Containment may also be difficult because Americans are more mobile (though I don't know if this is true); this video by Tectonix GEO shows how the cell phones of spring break partiers (known as Covidiots) on a beach in Fort Lauderdale spread to the rest of the country in the following weeks. This video shows how people from the New York metropolitan area spread over the entire US in the two days after Gov. Cuomo announced #stayhome rules. But millions of people left Wuhan for the Chinese New Year before January 25th, and yet China’s local authorities were able to prevent them from transmitting the virus locally by requiring visitors to isolate at home. Taiwan was also able to contact tens of thousands of residents who arrived from China to contain the spread of the epidemic. But the US does not have neighborhood associations and health authorities like Asian countries have.

It is not because China is authoritarian that containment was possible; it was because they had state capacity. The same is true for Taiwan and Korea. In part, the experience of SARS in Asia meant that states there prepared better. But the US is also underprepared because Americans, and especially libertarians and Republicans, distrust state power. Trump dismantled the pandemic response team in 2018 that had been created by the Obama administration. 

A weak state is not a bug; it is a feature of America. The Trump administration has been cutting budgets of all government departments, including the CDC. The “small government” ethos is strong in America. It is linked to ideas of freedom and liberty. You can see this skepticism of the government and of public health officials, that grows from a fear of state power, in websites like this of the libertarian magazine Reason.

No one knows what will happen with this pandemic; as thisblog post says, every model and prediction we read “is just a guess but with statistics.” (But he’s not simply dismissive; he adds, “All models are wrong. Some models are useful.”). And it is useful to go back to the Feb. 13 NY Times article interviewing Donald G. McNeil Jr., their health and science reporter who has covered epidemics since 2002, to realize how little was known as late as mid February. There are still important questions about the mortality rate, like why the rate is so much lower in Germany than Italy.   

But the chance for the US to contain the virus has passed. China, Korea, Taiwan, Hong Kong and Singapore have largely succeeded but are still fighting to contain the epidemic. In the US, because of a lack of testing and the debacle over tests, and because we don’t know how reliable the tests are anyway, we have no idea what percentage of the population has been infected. But now the US has passed China and has the most confirmed cases in the world. Rah rah patriots can cheer, “We’re number one!”

As long as people worry that going out will expose them to coronavirus infection, the economy will not rebound, even if authorities do relax restrictions. President Trump and a number of business leaders want people to get back to work, but the epidemic has to recede before people will go to the theatre, to the mall, and to restaurants, not to mention travel internationally and take a cruise. The chance to contain the epidemic has passed. Mitigation will be long and messy, and it is hard to know how and when it will end.

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