The Known and the Unknown

By Berel Rodal, co-director, GCPPP

With a nod to Charles Dickens’s It was the best of times, it was the worst of times, the pandemic crises may be remembered for our states of knowledge – what we knew, and didn’t know.

More precisely, perhaps, from the perspective of the present, expanding on Donald Rumsfeld, by what we know, and know we don’t know; and what we don’t know we know; and don’t know we don’t know.

Viruses are elements in the evolution of the Earth. We know that humans are prone to affliction by viruses, and that viruses are inevitable. Traumatic events in Western recorded history include among others the Plague of Athens in 429-426 BCE, with a toll in the order of 100,000 dead; the Antonine Plague, 165~190 AD, 5 million -10 million deaths; the Justinian Plague(s) in 541-549 AD, thought to have caused the death of quarter to one-half of Europe’s population; the Black Death in 1346-1353, considered responsible for 75 million-200 million deaths, perhaps half of Europe’s population; then, with many worldwide in between (Nicholas Christakis in his 2020 book “Apollo’s Arrow” notes that serious influenza pandemics recurred every few decades over the past three centuries), the ‘Spanish flu’ in 1918, responsible for somewhere between 17 million and 100 million deaths.

The past few decades brought the Asian flu in 1957-58 (1 million-4 million deaths), the Hong Kong flu 1968-70 (1 million-4 million deaths); HIV/AIDS from 1981 (approximately 35 million deaths); two respiratory syndromes that were Covid 19 precursors, SARS in 2002-2004 (916 deaths) and MERS, with about 900 deaths since 2012; and Ebola in many outbreaks since 1976.

So pandemics were, or should have been, familiar threats. Yet, other than for a number of Asian societies which drew knowledge and lessons, and were prepared for a repeat – Japan, China, Taiwan, Hong Kong, Singapore, South Korea, Vietnam – a striking feature of the Covid-19 crises is that much of the rest of us didn’t know what it was that we knew. We know well how shockingly unprepared otherwise advanced societies were with the onset of Covid-19, even in basics – the supply of protective gowns and masks, for example.

This is in spite of the fact that pandemic preparedness had figured in each major country’s national security risk assessments in preceding years. Might this speak to the role of stakeholding and of the incentivizations built into our health ecologies? To a political unwillingness to devote resources to a social, rather than military, threat? The world’s most expensive health systems were found wanting, also but not only (per Shakespeare’s Richard III) for want of horseshoe nails.

Today, less than a year since it so dramatically came to delimit our horizons, Covid-19’s evolution is the best understood of any newly-appearing disease, thanks to the modern-day equivalents of the Manhattan Project and Apollo programs, as Edward Yong observes in his magistrale article in the January/February issue of The Atlantic (“How Science Beat the Virus”). He notes that the biomedical library PubMed today lists more than twice as many scientific papers for Covid-19 as there are for polio, measles, cholera, dengue, and other diseases that have plagued humanity for centuries.

Diagnostic tests are now available to detect the virus within minutes. Vaccines have been developed and are being deployed at previously unimaginable speed. The Global Commission’s Pardis Sabeti observes that “We’re learning about this virus faster than we’ve ever learned about any virus in history”. Edward Yong considers that this may be because Covid-19 is personal for scientists, as indeed it is for all of us. Unlike Ebola, for example, Covid-19 threatens to inflame their lungs, and shuts down their labs. And because vast funds flow.

Yet this expansion of the domain of known knowns should not obscure the importance of the known unknowns. Known unknowns include, in the medical sphere, the length of time vaccines protect, and whether reinfection and transmission remains possible; why Covid-19 causes no symptoms, or mild symptoms in some, severe or deadly illness in others; and include the longer-term effect of viral infection, of “Long Covid” in particular. Many suffer lingering or enduring effects. Little is yet known about understanding, preventing, and treating these. We are warned to expect a continuing, even growing, wave of long-haul symptoms and suffering. There is growing advocacy of focussed study of this dimension of the experience of Covid, also to shed light on the broader problem of pathogens that cause pandemics – another of which is inevitable.

Among the known unknowns are the otherwise avoidable suffering and death resulting from illness untreated for want of medical resources, diverted to deal with Covid. A deep known unknown is the mental health effect of the crises, resulting from isolation and loneliness, anger and loss, anxiety and distress, sadness, and bereavement.

A critical known unknown, or perhaps it is known but so far relatively unaddressed, is the societal dimension of the pandemic crises, including the cultural dimensions of illness, often obscured by the “biological bias” of medicine. The evidence made salient and harder to ignore of the disproportionate effects of pandemic infection, disease and death, and related ills, on people in disadvantaged or poorer communities, in crowded or hazardous living conditions, with less access to health care, brings more to the fore a need to re-imagine medicine, at training, practice, and political levels. It brings to the fore a need to incorporate or rather reincorporate the societal and cultural in the understanding and treatment of illness and healing, and in the organization and delivery of public health.

By their nature, the future effects of the pandemic crises are as yet unknown because they are unknowable at this juncture. Still, some suggest themselves already – change in how work, commerce, and education are conducted, the role of digitalization and of Artificial Intelligence. Major known unknowns about future impacts include the long-term effects of the pandemic crises on social cohesion and political legitimacy, including dynamic consequences of loss of face, faith, and center; the potential for toxic widening gaps in security and economic opportunity; the consequence of overhanging public and private debt; and the effect on an already dysfunctional international order. And perhaps, closest to home, the effects on and for children deprived of schooling, again differentially; to say nothing of the developmental impact on the young deprived of normal peer and social connection.

We are only approaching the end of the beginning of the multiple, interconnected crises of the pandemic. Might a return to normal might be in the cards, as many hope?  Historical example suggest that the major social, political and geopolitical impacts develop and emerge over a number of years rather than in the heat of the pandemic itself.  Such known unknowns include the deeper, structural economic and geopolitical impacts of the perfect storm of crises in train. Historically, pandemics like devastating wars have wrought tectonic change, making salient changes and exposing gaps in development for years, advancing and bringing into view a reordering of norms and power.

And then there are unknown unknowns which the pandemic crises invites us to reflect on, worry about, and guard against more vigilantly than did too many societies with regard to the pandemic in progress. While the future is unknowable, we can yet see, if through a glass darkly, social, political, and geopolitical challenges and perils history and the present teach us may lie ahead, calling on us to be better prepared or at least more resilient.

The Hebrew Bible includes a somewhat mystifying incident (at Genesis Chapter 11) of a human project to build “a tower with its top in the sky, to make a name for ourselves”.  Following the story of the Great Flood, one may understand this as the human effort to get above the level of flood waters, to build invulnerability to the forces of nature. Indeed, “to make a name for ourselves” might be understood in today’s terms as the effort to control our genome. The Tower project, we read, is divinely frustrated. The message, possibly, is to tell us that vulnerability is basic to the human condition, that to be human is to have the future come at us from the dark, inviting us to focus on what builds individual, community, societal, and global resilience in the face of perils known and unknowable.

Discerning the forces in play, seeing and communicating connections, enabling insight and a view of the broader prospect – all these our current state requires of us. And yet inviting us also to reflect on, in the words of the great Irish poet William Butler Yeats, writing at another time of uncertainty

And what rough beast, its hour come round at last,
Slouches towards Bethlehem to be born?