### Horror

Today’s media are breathlessly reporting that the WHO is predicting 5,000 – 10,000 new cases of Ebola virus disease per week by the beginning of December. There is no written documentation on this, but I did find this study in the New England Journal of Medicine (NEJM) from the WHO’s rapid response unit which suggested 20,000 cumulative cases by 2nd November, which would be 10,000 more cases than we are seeing now (roughly) in just two weeks, so 5,000 per week in November. Given the doubling times in that study were estimated to be approximately one month, that does suggest a rough number of 10,000 cases per week by December (if anything that number is probably slightly optimistic). If so we can expect to see 40,000 cumulative cases by the start of December (20,000 to 2nd November, then 20,000 more in November), and 80,000 by the end of the year. Assuming the same doubling, we will see another 20,000 a week in January, which takes us to a rough 150,000 by the beginning of February, assuming that there is no successful intervention by then.

The case fatality rate is now estimated to be about 70%, so those time frames would give respectively (and approximately); 30,000 deaths by the start of December; 55,000 by the end of the year; and about 100,000 by February. Those are large numbers, but on a national basis what does that mean? In this post I want to look at the implications of these numbers under three different scenarios, but first let’s just look at the number of deaths by the end of the year, and do some rough calculations of the implications.

First, let’s look at just Liberia. The NEJM article puts about 50% of all cases in Liberia, so if we follow that proportion forward, we can expect about 27,000 deaths by the end of the year, and 40,000 cases. It’s not necessarily wise to assume that proportion is static, since the disease appears to have taken hold in the capital of Liberia and Liberia seems to be the worst affected, so the disease may spread faster there or may burn out sooner; but for lack of better evidence let’s just go with that proportion. Liberia, according to Wikipedia, has a population of 4 million, and its capital Monrovia has a population of about 1 million. At first blush, 27,000 deaths is not a lot of people in a country of 4 million … but in 2005-2010 Liberia’s mortality rate was 12 per 1000, for a total of 48,000 deaths in 2014 (my estimate). The 30,000 extra cases of Ebola in Liberia that will occur by the end of the year will cause 21,000 deaths, 50% of its annual total. In just 2.5 months the disease will kill as many people as usually die in 6 months. That’s a traumatic increase in mortality, such as usually happens only in times of natural disaster and war.

In addition, however, controlling the epidemic requires isolation and monitoring of an enormous number of people. Consider this report of an outbreak of Marburg disease in Uganda in September. The disease – which is very similar to Ebola – was identified in a single person in a small town in Uganda, and killed the index case after 17 days. Contact tracing was carried out, and the WHO reports that

As of today, a total of 146 contacts have been identified and are being monitored for signs and symptoms compatible with MVD. Eleven of the contacts developed signs and symptoms compatible with Marburg virus disease.

In order to properly contain this disease, the doctors had to track down 146 people, and of those 11 developed signs and symptoms (fortunately in this case none of them were positive). In the Liberian context this would mean that for every case, more than 100 people need to be traced and 11 isolated as suspected Ebola. Even if we assume that people are starting to catch on to the risks, and so are having less contacts and less need for isolation, we can probably still safely assume that to properly control the disease we need to isolate 4-10 people and trace 100 or so. For 30,000 new cases from now till the end of the year that will mean isolating 120-300,000 individuals, for a period of as long as 21 days. The top end of that figure is about 8% of the population of the country.

Finally, the toll on health care workers of the first 10,000 cases has been genuinely shocking. The latest WHO situation report tells us that 201 health care workers in Liberia have caught the disease, and 95 have died. Assuming that rate persists, adding 30,000 more cases will lead to the death of 300 more health care workers. Wikipedia, again, tells us that Liberia had 5000 full- or part-time health care workers in 2006, of whom 51 were doctors. By December Liberia will have lost almost 20% of its entire health workforce, leading to huge setbacks for health in one of only seven countries in Africa to have met its Millenium Development Goal 4 (under-5 mortality) targets.

So let’s bear those basic figures in mind. 40,000 cases= 28,000 deaths, 120-300,000 isolated individuals, 1.2 – 3.0 million individuals being monitored for signs and symptoms, 20% of the health workforce dead. Also, a very large number of foreign health workers coming in to help, and entire new hospitals being constructed in a country with no suitable infrastructure. Now let’s consider three different scenarios, based around the UN’s 70-70-60 goal, which is to be able to isolate 70% of cases and bury 70% of bodies safely, within 60 days. The low basic reproductive number of Ebola – below 2.0 in most cases – means that preventing 70% of secondary cases should be sufficient to kill the epidemic (just!) So let’s assume that if this goal is reached and maintained, the epidemic will plateau and then begin to decline, in about the same time that it took to escalate. For simplicity we’ll count that time period in terms of numbers of cases – so after the disease peaks, we will assume as many new cases occur as the disease fades away as occurred in its growth. This is not unreasonable – most epidemic patterns don’t crash, but tend to go through a decline that looks roughly symmetric to the increase. This may not apply with a disease as fatal as Ebola, but no one will know till we come out the other side, so let’s assume it will behave as most other epidemic patterns do. This means that if we have x cases by new year, and the UN goal is attained at new year, we should expect to see a further x cases before the disease is gone.

The best case scenario: Liberia meets the UN goal on time

If the sudden inrush of aid workers and soldiers enables Liberia to meet the UN goal on time, we will reach 70-70 in 60 days from now, i.e. by mid-December. That means there will have been 60,000 cases by the time the epidemic begins to decline, or maybe 100,000 by its end. This means 70,000 deaths, 300-700,000 isolated individuals, and pretty much everyone in the country being monitored. About 50% of the workforce will be dead. If we assume the decline takes a few months, say until March, we can guess that we will see nearly two years’ mortality in just 6 months. Between 10-25% of the population will have been isolated for about one month during this period, unable to work or care for others. The goal of safely burying 70% of the dead means 50,000 bodies will need to be buried by specialist teams. The difficulty of their work can be seen in this excellent brief report from the NY Times, but I think it’s obvious that burying 50,000 bodies is going to have to be done in a very different way to this. I wonder if there is even a protocol for mass burial of highly-infectious bodies?

This is the best case scenario. On the basis of the numbers alone it is clearly a catastrophe for Liberia, but it isn’t enough to bring the country to its knees (at least with outside help). Less than 2.5% of the country is dead, and although the economic effects are alarming and the long-term destruction of the health system will set the country back years from its health goals, it doesn’t appear to be a recipe for total collapse (at least on paper). There is hope here, and if the containment efforts are good so that the epidemic crashes really fast, then we can expect it to have a much less significant effect on the health workforce.

The realistic scenario: Attaining 70-70-60 a month late

Suppose instead that the UN goal is missed by a month, taking us to mid-January. That will correspond with about (very roughly) 100,000 new cases by the time the epidemic peaks, or 200,000 by the time it finishes in probably March or April next year. From our calculations, this means 140,000 deaths, 600,000 – 1.5 million isolated individuals, and the remainder being monitored. The entire health workforce will die in this scenario, and about 100,000 bodies will need to be buried safely. Only 54% of the Liberian population are working age, or about 2 million; it’s quite possible that a large part of the adult workforce will be in isolation for more than 3 months, with a large part of the rest involved in basic Ebola-combat activities (burying bodies, contact tracing, logistics). The death toll is equivalent to three years’ mortality in 6 months. What this would mean for the agriculture sector I cannot guess, but it doesn’t seem good. At this level of disease spread, I think we are looking at a society on the verge of collapse, where trade-offs have to be made between isolation/contact tracing on the one hand, and maintaining basic functions of civil society on the other. If the UN goal is missed by a month, alternatives will need to be found to isolation systems, and a huge increase in available health workers will be needed.

The worst case scenario: Failure to contain the epidemic by February

Failure to contain the epidemic by February means 150,000 cumulative cases by February, and probably at least 300,000 (maybe more) over the next few months, with no sign of a slowdown. Every month we will see another doubling of the rate (40,000 per week in March, and so on). Just taking the minimum value here of 300,000 cases, there are 210,000 deaths, 840,000 – 2 million individuals in isolation, and the entire health workforce decimated. In this scenario most of the adult working-age population is isolated, and the entire economy has shut down. Without a huge influx of foreign aid – in food, water, field hospitals, and probably thousands of medical staff – the disease will break out of any containment system that might be left in place, and the only limit on its spread will be its own voracity. This suggests to me that we have until January to get an effective containment system in place, or Liberia as a country will cease to exist in any functional sense. We should assume, furthermore, that in the general breakdown of the social order that will ensue many people will leave the country, and the risk of the epidemic spreading to Nigeria will be very great.

Caveats and limitations

These figures are all rough guesses based on huge assumptions. The number of people who need to be isolated will not scale linearly with disease spread, for example, because one individual will begin to have multiple case connections, and as the disease spreads and social contact reduces, the number of people a new case will have actually touched or been near will decline rapidly. So my estimates of effects on the working age population are inflated, and these are the key cause of social breakdown, I think. Without the effect of isolation and disease containment efforts, even 300,000 cases and 210,000 deaths is not a society-ending event in a country of 4 million people, though nobody wants to think about how horrible that will be. My assumption that the downward side of the epidemic will cause as many cases as the upward side is based on the assumption that the basic reproduction number will be reduced only just below 1 by the 70-70-60 plan; this means each existing case gets a chance to cause another, but if the epidemic is contained more effectively once the plan is in place that assumption could be an over-estimate. Also there are geographical limits on the spread of the disease (especially once things get desperate and all travel within the country is shut down); this will mean that the disease rapidly burns through its available cases and dies out before it can spread fully. And finally, I don’t know what the time trend in deaths of health workers is, but I suspect these deaths were mostly in the early stage of the disease before the word was out, and that deaths are now declining rapidly towards zero. Given all these constraints, I think that an aggressive plan enacted now, aiming to achieve the 70-70-60 goal, and followed through aggressively thereafter, will probably stop the disease somewhere before the numbers provided in my best case scenario. This will still cause a years’ worth of mortality in a couple of months, take up to 10% of the working age population out of work for isolation, and kill up to 20% of the Liberian health workforce. It won’t cause a national collapse, but it is a catastrophe easily as bad as a tsunami or some other huge natural disaster.

What should this mean for the future of health planning in Africa?

We often talk about “fragile health systems” and “extreme poverty” in Africa, but in the rich nations we’re used to thinking of health system failure as poorly-managed diseases and unpleasant medical experiences, but it’s worth remembering that at the extremes of medicine there are disasters: car accidents, pandemic influenza, and incredibly horrible diseases like Ebola. In the best of times in Africa, “fragile health systems” means excess deaths due to preventable infant, maternal, HIV- and malaria-related mortality. But in the worst of times it means huge waves of mortality due to natural disasters, war or epidemics. This Ebola outbreak is showing the rich world what “fragile health systems” really means, and also showing us that we are not able to completely disconnect ourselves from these failures. We can’t expect to isolate ourselves from emerging infectious diseases forever, except perhaps at the cost of our humanity, so instead of trying to isolate ourselves we should try to seriously tackle the fundamental problems affecting health systems in Africa and some parts of South Asia. This is not like a military intervention where the best of intentions can bring about the worst of results; we know what works and we simply need to find the political will to make it happen. Once this disease is back in its box, and all three affected countries are able to contemplate a return to normality, we in the rich world should make a serious, final effort to fix global poverty and most especially to end the grotesque inequality in health systems around the world. It’s almost certainly not going to happen, but we have to recognize that any country with a fragile health system is one weird event away from a terrible humanitarian catastrophe, and we need to start thinking about how to stop this from happening again. That means we have to act to help those countries to genuinely strengthen their health systems, and achieve the kind of economic state that is able to sustain them. This may mean we fat, rich westerners pay a little more for our chocolate, coffee and clothes, but it’s a price I hope we are all going to be a little more willing to pay now that the threat of dying horribly in our own body fluids has begun to make itself felt.

This situation should also serve as a warning about the dangers of ignoring very rare but high-risk events. Ebola has been known for 40 years, and this is the first time it has ever escaped containment. Work on a vaccine has been delayed or ignored partly, I think, because the risk of this disease escaping its bounds is so low that people considered it negligible. I hope my calculations show that the cost of this disease is only negligible provided it never happens, and that once it does happen all our risk assessments look incredibly stupid. We need a new way of assessing risk which puts a serious value on low-probability events. In the era of climate change the implications of this are obvious. At the tail end of some of the global climate models there are some extreme, civilization-ending events that have been largely overlooked by policy-makers because they are so unlikely to happen. Hopefully this Ebola outbreak will convince the world that it is time we started looking more at the tails of our probability distributions, and not at the comforting bulges down near the low-cost events.

Commencing case isolation protocol 666

Media reports today that the Spanish government has killed a dog. Not just any dog – this was Excalibur, the hapless pet of the nurse who is quarantined for Ebola in Spain. The nurse, Teresa Romero Ramos, is being treated for Ebola after contracting it while treating a returned missionary; her husband is in isolation to be monitored for signs of the disease, and there are fears that the dog might have it too. It’s not clear whether dogs can get or transmit Ebola, though there is some vague evidence that they are at least at risk, so in theory there was some justification for the execution of an innocent dog, but in my opinion this is a huge public health mistake.

Because there is no treatment for or vaccine against Ebola, our only effective intervention to prevent its spread is case isolation, which in turn depends on early identification of cases, and rapid and effective contact tracing. This method alone has been effective in every previous outbreak. Although not airborne, Ebola is highly infectious with close contacts, so early identification is important to reduce the subsequent contact tracing burden, but symptoms are vague (fever) and easily confused with other possible illnesses – especially as influenza season approaches. So it’s really important that people with fever be willing to attend a doctor early, and that they be willing to risk putting their lives into the hands of public authorities on the basis of nothing more than a suspicious fever.

This kind of early identification, case isolation and contact tracing depends fundamentally on trust. The person with a fever needs to trust that they and their loved ones will be treated well, and that people contacted through them will be treated well. In general – I’m going to go out on a limb here – shooting someone’s dog does not fall under the definition of “treating them well.” It is, in fact, kind of mean.

Of course we all know that in times of emergency, the government will kill our dogs. If Ebola jumps the shark, you can bet that pets of all kinds will be seen as mere collateral damage in an extremely authoritarian and aggressive public health response. But since we don’t want our society to get to that point, our first goal in public health responses should be to ensure that everyone who might need to attend a doctor does so as early as possible, without fear of the consequences. Notice the emphasis on might – that is an important word in this context. If you want to give people the impression that they don’t need to fear the consequences of reporting their fever, you probably shouldn’t shoot their dog.

Now, many people might think that this is a public health emergency and in public health emergencies dogs aren’t very important. This is probably very true. But a public health response has to be built on the possibility that not everyone will agree with you about that; or that they might not understand the dynamics of infectious diseases enough to realize the dangers of letting their dog go; or that they might not have the same understanding of their own disease risk that you do. If anyone who thinks in any of those ways gets Ebola, and you have given them reason not to trust the authorities, they will delay their attendance to a hospital, and/or lie about their circumstances. This doesn’t just extend to crazy scenarios like refusing to admit they have Ebola because they don’t want you to kill their dog. The most likely scenario is much more bland: someone with a fever misjudges the risk that it is Ebola, and because they have a general worry that their dog will be shot if they go to hospital, they decide to just “wait and see” for a few days. During that few days they definitely infect their dog, and a few other people, before they finally accept that the bleeding eyes are the giveaway that they really do have Ebola.

But shooting a dog isn’t just about dogs: it’s about the general possibility that you’ll be treated like shit just because you have a fever. There are lots of other situations where such a fear could cause delay: the dude who has a fever but spent last night cheating on his wife, and is worried that a government that shoots dogs won’t be particularly discreet about contact tracing; the potential Ebolaee who has friends with prizewinning breed dogs, and doesn’t want to have the government shoot their friends’ dogs so decides to just wait a few days to be sure it isn’t Ebola; the person who gets really sick at work, but whose cat is outside, decides to check himself in to hospital but figures cats don’t talk to strangers, and doesn’t want all the cats in the neighbourhood being shot, so doesn’t mention it; the dog lover who doesn’t think they have Ebola and doesn’t want to take the risk, so hands their dog to a neighbour before going to hospital. Any one of these scenarios is a potential nightmare of contagion, and they can break down at any point in that identification-isolation-contact tracing process.

Obviously when the outbreak goes epidemic, this will all become academic, but right now it’s not epidemic: there are a few people under observation, and two people in quarantine. The decision to kill the dog sparked a global protest. Would it really have been so difficult to tranquilize the dog, put it in some kind of quarantine, then tweet pictures of it with a dumb-arsed chewy toy and the phrase “Spanish healthcare: no dog left behind”? A tiny bit of extra work, for a huge public relations win. You can always shoot the dog a few days later and claim it got Ebola and it was the “humane thing to do.” If you really really can’t figure out a way to keep a dog alive for a few days without touching it, I think you aren’t really trying – and I think every pet owner will agree with me about this. Also – and this might prove important later in the epidemic – we don’t know if dogs can transmit or even become symptomatic for Ebola. It might be nice to know that, and right here we have a dog with potential Ebola. More specifically: there are a lot of cat owners out there, and cats wander, and fight. If one of those cat owners has Ebola and lets their cat out at night, it would be really really handy to know whether domestic pets are a risk. If only we had a dog with Ebola … oh, but we shot it.

Basically the Spanish government just told everyone who thinks they might have Ebola that even though they are nowhere near emergency stage, they’re already willing to act like complete dickheads. So anyone who has a fever and something to hide, a pet, or a group of people they really don’t want to annoy, is going to be thinking that maybe they should be really sure that it’s Ebola before they cash in everyone they know to a pack of ruthless dog killers. That suspicion may only delay their presentation for a day or two, it may only make them lie a bit during the contact tracing phase, but that’s enough – the disease gets spread. And as we have seen from Africa, stopping the spread of this disease early is crucial to stopping it at all.

Also, if I survive Ebola, I would quite like to go home to rapturous greeting from my (uninfected) dog. Shooting Excalibur was just a dick move.

Since I’ve been talking a bit about HIV lately, I’ve also been thinking about Ebola, and so while I’m here I thought I’d make a few other points about the media treatment of Ebola, and the associated public perception, that I think are important. I also would like to share the Science collection of articles on Ebola, which have been made open access for the duration of the epidemic. These include some fairly accessible media descriptions of the issues, and also some interesting survivor interviews. The Guardian has also devoted one of its (horrible) live “Blogs” to a day of coverage of Ebola, which is reasonably informative (it also includes survivor interviews). Make no mistake: this disease is easy to prevent and really, in the modern era, should not be a serious public health threat, but it is a terrifying phenomenon once it gets wild.

Ebola is not less important than Malaria and HIV

Quite a few media articles have been complaining that Ebola is getting more attention than malaria and HIV, which are the worst killers in Africa. Articles on this theme usually show  a mixture of motives, primarily a desire to criticize media sensationalism, complaints about westerners just throwing money at dramatic attention-grabbing problems rather than core health problems, criticisms of the amount of money available in aid[2] for these major diseases, general bullshit about the WHO[1], or misjudgments about risk. But let’s be clear about this: it’s a completely bullshit argument, probably racist and definitely annoying. First of all, huge amounts of aid money are committed to malaria and HIV every year: the Global Fund, Bill and Melinda Gates Foundation, WHO, PEPFAR, GAVI – there are billions and billions of dollars, whole inter-governmental organizations (e.g. UNAIDS!) and large portions of international aid budgets devoted to the biggest killers in Africa. They are not under-resourced, though of course all these diseases could (and should) have more money. Also this disease is not something you can sensationalize enough: read the reports from survivors, and you see that it is a truly terrifying and destructive phenomenon. It is also possible for us to walk and chew gum at the same time: pouring resources into Ebola doesn’t suddenly mean HIV will lose its money, and if anything the opposite will happen: a society forced to commit all its medical resources to a sudden wildfire epidemic will not be able to maintain routine health care, and other conditions (in Africa, maternal and child mortality) will get worse. This is a fairly obvious thing to say, but because opinion writers are usually idiots, it needs to be spelled out: a society facing a medical apocalypse cannot also maintain routine maternity services. As an example of this, I know a man whose cousin had arranged work as a paediatrician in Sierra Leone, starting in November. She’s now changed her plans, and will be starting work in an Ebola containment ward next week. That’s what happens when a hemorrhagic virus goes full retard: paediatricians don 77 layers of rubber and head into the hot zone.

But the thing that’s most annoying about this article is its reduction of all of Africa to a single entity, or as the infectious disease blog haba na haba put it, Ebola is only the Kardashian of diseases if you think Africa is a country. Yes, malaria and HIV kill lots of people in Africa, but the death numbers for these diseases cover the whole continent. Ebola is killing people in just three countries, and it has probably now killed more people this year than HIV and malaria combined in those countries. Unless you think national boundaries don’t matter for health and economic policy, it should be fairly obvious that while most of Africa is struggling primarily with HIV and/or malaria, in these three countries Ebola is a catastrophe unfolding on a grand scale.

This last argument comes down to another simple problem with modern media and their interpretation of health policy: misinterpretation of risk.

Ebola is only harmless while we make it so

Ebola is not as infectious as measles or mumps, or even HIV, but it is remarkably virulent and its ability to infect people after death means its growth is not necessarily constrained by its high case fatality rate. This makes it a rather unique virus. But there are many articles in the media suggesting that we are over-reacting to Ebola, and that it is not that serious a concern. These articles are largely based on past experience of Ebola, but they miss an important point about how we manage disease outbreaks: Ebola is only not a threat so long as we take it very seriously. Provided we take Ebola seriously, and act quickly to stamp out even the smallest evidence of it, it is not a serious concern. If we decide that therefore it is not a concern, and lower our guard, it will spread and cause huge damage. But the various critics of epidemic policy are always looking for the latest disease threat that didn’t materialize – SARS, avian flu, H1N1 – and claiming that the health authorities overreacted, when in fact that “overreaction” is the main bulwark between civilization and chaos.

And if you want to see what happens when that bulwark collapses, visit the Ebola zone now. In this article, Senga Omeonga talks about his colleagues who were struck down by Ebola. He is a doctor, and only just survived the disease. He says, of his small unit,

In total two brothers, a Spanish priest, a sister, two nurses, one x-ray tech, one lab tech, and one social worker died. Two other doctors, two sisters, and one orthopedic tech survived. They closed the hospital after the outbreak.

So many skilled health workers died because of one index case. Ebola preferentially targets healthcare workers, and the associated people who are needed to support the work of doctors. Even if these countries manage to defeat the disease, they are facing a future with a massively depleted healthcare workforce. Some of these countries have less than 100 doctors, and less than 1000 nurses: every single death in this workforce is a huge loss, and the loss of a massive amount of national capital. Even if the disease doesn’t spread enough to decimate the population – a possibility that is looking increasingly likely – it is probably going to set the health development program in these countries back by decades. The result of this epidemic will be a long-term reduction in capacity to handle HIV/AIDS, malaria and maternal and child mortality. But a lot of coverage of this disease is predicated on the assumption that health systems are overreacting, and that the disease can be assessed simply in numbers of deaths, rather than their strategic location; and a lot of media reports (and let’s face it, probably a lot of government policy) has been focused on the risk of rich nations being infected, rather than on the threat to health systems in poor countries.

Once the health system collapses, any disease gets a free run. The health systems in these countries are on the brink. Even the World Bank – which has spent years resisting Universal Health Coverage – has been forced to recognize that these health systems are fragile and underfunded. When these countries emerge from this epidemic, let’s hope that western governments will have finally learnt the lesson global health policy makers have been pushing for years, and recognize that in an interconnected world robust health systems are a social good. Maybe then they will start to find creative ways to create the fiscal space for effective health systems in even the poorest countries. Any program that looks for such a fiscal space is going to need to recognize that poverty and underdevelopment do not support universal health coverage, and make policies to genuinely support economic growth. Let’s hope Ebola is a turning point towards shifting the economic relations between low- and high-income countries, to the unequivocal betterment of the former.

fn1: If you google “ebola WHO priorities” you’ll find this article by Henry I Miller being syndicated across the world. It’s incredibly negative about the WHO – the organization that eradicated smallpox! – and also incredibly wrong. It’s worth noting that Henry I Miller was specifically identified as an advocate for Big Tobacco in the Tobacco Papers. The campaign against tobacco is one of the WHO’s greater success stories, so it’s no surprise that he takes every opportunity to slander the organization, and no surprise that the Hoover Institute is willing to employ someone this oily. It should come as no surprise, then, given the history of Big Tobacco in funding global warming denialists, that this greasy little man is also a global warming denialist. Yet idiot newspapers around the world have reproduced the anti-WHO rantings of this paid defender of Big Tobacco. Do they have any understanding at all of how to check sources?

fn2: I particularly like the use of a picture of a semi-naked dead person being sprayed with disinfectant at the top of an article about our “empathy deficit.” Stay classy, Huffington Post!

He likes the smell of new viruses in the morning

This week the journal Science reports a new study finding HIV first emerged in Kinshasa (now the Democratic Republic of the Congo) in the 1920s – not the 1970s or 1980s as previously suspected. The disease was likely introduced to Kinshasa through bush-meat, but spread rapidly across the Congo through mobile workers moving on Belgian-built train networks. At that time the region was a Belgian colony, and labourers were moving across large areas of the country as they moved to and from the capital and large mining areas in the hinterland. The article also reports that Kinshasa itself had a large and active sex industry in support of he transient labourers, and this may have helped to spread the disease. It’s an interesting story of virology, archaeology and globalization.

What I find fascinating about this story is that HIV took hold in the 1920s, but wasn’t identified as a disease until the 1980s, despite the presence of medical and public hygiene programs in Kinshasa, the growth of tropical medicine as a discipline, and the presence of major militaries in the area during both world wars (most notably the Force Publique, a force of some tens of thousands of black Congolese soldiers led by white Belgian officers). Typically the military establishment pays careful attention to hygiene and to STIs, especially since the work of Florence Nightingale, but somehow during all this period they missed HIV as a disease. In fact, this new research suggests that the success of the entire discipline of Tropical Medicine should probably be reassessed.

The reason that HIV was not identified is, I think, quite simple: it has a very long asymptomatic period, up to 12 years, and it does not manifest through a single set of coherent symptoms, like measles or flu, but through a complex of opportunistic infections. The case definition for AIDS is complex and depends on a list of AIDS-defining conditions that have few commonalities, so it is extremely hard for a doctor seeing these cases in disparate people to identify a single underlying condition. Instead the symptoms are treated, and the patient dies. From the point of view of a doctor in 1920s Belgian Congo, finding an underlying cause would be almost impossible. First the doctor might see a soldier with recurrent herpes, then a miner with a rare and untreatable cancer, then a sex-worker with repeated bacterial infections. Some of these people might have got the disease sexually, some through infected needles during a vaccination drive, perhaps the soldier might have exchanged blood in a fight – 10 years ago. It’s just not possible to identify a cause in this case, or to see a common pattern.

So I guess we have the unfortunate sacrifices of a significant proportion of gay men in one generation in the USA to thank for our discovery of HIV. By the time the full scope of the disease and its origins were understood, HIV was already out of control in Africa, to the point where it was causing major social and economic problems, and it’s possible to imagine real economic and social collapse happening in some parts of Africa if the disease hadn’t been identified for another 10 or 15 years – especially if by the time of its identification the rich countries were also burdened with a generalized epidemic and facing their own public health (and potentially economic) emergencies.

Which leads to a horrible speculation about the past. Would human society have survived if HIV had emerged 500 or 1000 years earlier? With death following a pattern similar to non-communicable disease and old age, no coherent virological or bacteriological principles, and the point of infection distal from the point of symptom onset, it would have been almost impossible for human society to identify the existence of the disease, let alone its cause. Worse still, HIV is transmitted from mother to child, with very high mortality rates in children, so it would have spread rapidly over generations and had huge mortality rates. Once widespread the disease is economically highly destructive, since it forces communities to divert adult resources to caring for sick adults who should be in the most productive part of their lives. In the absence of a known cause it would simply be seen as “the Scourge,” but in the absence of well-kept statistics on life expectancy and mortality rates, it might be difficult for societies to realize how much worse their health was than previous generations.

In that period there were other diseases – like the Black Death – that had an unknown transmission mechanism, but these were identified as diseases and (mostly erroneous) methods put in place to prevent them, with of course the final method being case isolation and quarantine, a technique that usually has some success with almost all diseases. But these diseases differ from HIV in that there is a rapid progression from symptom onset to mortality and the symptoms are visible and consistent, making the Black Death clearly definable as a disease, which at least makes quarantine possible. With a diverse range of symptoms, a long period from symptom onset to death (often 2-3 years) involving an array of different infections, in a society where death from common infectious diseases was normal, people just would not notice that they were falling prey to a single, easily preventable disease, so even quarantine or case isolation would be unlikely to be implemented. Another difference between HIV and the Black Death is the long asymptomatic phase of HIV guarantees its persistence even though it has a nearly 100% case fatality rate; whereas the Black Death spread through communities so fast that it soon burnt out its susceptible population, leaving a community with some immunity to the disease. HIV is not so virulent, or so kind.

I think if HIV had spread from Africa 500 years earlier, it’s possible that the majority of the human race would have died out within a century or two, leaving whole continents almost empty of people. I guess the Indigenous peoples of the “new” world would have escaped the scourge, leaving the earth to be inherited by native Americans, and most of Europe and Africa to fall to waste and ruin. It’s interesting to think how different the world might have been then, and also chilling to think how vulnerable our society was in the past through ignorance and happenstance. A salutary lesson in a world where we live ever closer to nature, but where many societies still have health systems that are too fragile to handle the challenge presented by relatively preventable diseases like Ebola virus. The Science paper also presents a timely reminder of the importance of being prepared for the unexpected, and the dangers of complacency about the threats the natural world might offer up to us in future …

This month’s Scientific American has an interesting article about the colonialist routes of the modern conservation movement, focusing on the role of John Muir in the foundation of Yosemite National Park. John Muir was the charismatic founder of the Sierra Club, a big organization in the conservation movement internationally and especially in the USA. John Muir was also an enthusiastic genocider:

his position was that of champion for a mean, brutal policy. It was in regard to Indian extermination[1]

Muir thought of the native Americans of Yosemite as “hideous” and “strange creatures,” and had no respect for them. He wrote that

they seemed to have no right place in the landscape, and I was glad to see them fading out of sight down the pass.

Which is an interesting example of how counter-productive such racism can be. The article presents compelling evidence that those people who had “no right place in the landscape” had actually carefully shaped the entire conservation area through generations of traditional slash-and-burn farming practices, which Muir ignored or actively reviled, with the consequence that the park lost much of its original beauty and character within Muir’s lifetime.

It is of course no surprise that an enthusiastic proponent of genocide should refuse to listen to or respect the ideas of those whose land he stole, and a bitter dreg of schadenfreude that his ignorance and racism led to the corruption of his dream stolen property. That will no doubt have been of little consolation to the men, women and children murdered in pursuit of his conservationist dream.

I wonder if the desire for pristine wilderness amongst those early conservationists was driven at least partly by a desire to reach an itch in the conscience that couldn’t be scratched. No humans on the land means being able to look away from what you’ve done, and to maintain a pretense of terra nullius, that the land was never occupied anyway, that those people who “have no right place in the landscape” were just drifting through anyway – only white men can touch the land in a way that leaves indelible marks, and to the romanticist those marks can only be the cruel marks of industry. So the only solution to protect the land from the evil touch of men is to set it aside – and carefully look away from the fact that the land was being nurtured by red men before you came and took it.

From this guilty itch and wilful blindness was formed the impulse to set aside land for conservation – the essence of the modern conservation movement. There is no doubt that this movement has done a lot of good for the environment, but it’s worth remembering the bloody crucible in which that impulse was born, and wondering how different the modern conservation movement would be if Muir had listened to those people he wand to see “fading out of sight,” instead of hastening their journey down the pass …

fn1: these are the words of his future wife’s friend. They should serve as a reminder that at the time of genocide in America and Australia, opinion was not settled on the rightness of the matter, and those who commissioned the deed were well aware that there was debate as to whether it was right.

If you go down to Gotanda today …

On Sunday I played a quick(ish) game of Malifaux with two of my regular role-playing crew. This was my first ever game of Malifaux, and I was quite impressed – it’s a smooth and enjoyable small squad battle game, with a cute mechanic and powers that are easy to learn, as well as very pretty design and a rich atmosphere. This is a brief report of the battle, which ended in a brutal all-party conflagration in the middle of the field.

Don’t go to the nursery, dreamer, you won’t like what you see …

I played the Neverborn, and my foes were the Resurrectionists and the Guild (I think). We played on an 8×8 battlemat, with two strategies each. My team were:

• Zoraida, a leader with a heavy magical bent
• Teddy, a big furry bastard with teeth
• Baby Kade, a small and unpleasant child with nasty knives
• Candy, a blank-eyed Goth Lolita with a bag of poisoned sweets
• Terror Tot, your classic vengeful infant
• Sorrow, some kind of spirit creature with a mean turn in misery and pain
• Voodoo Doll, Zoraida’s totem and a big mistake

The Guild player, Big R, went for a small squad of Death Marshalls, the Scales of Justice and some random guy with a big hammer (?) who died. The Resurrectionist player, Aloha-san, went for an absolutely brutally murderous leader called Seamus, some gravedigger dude, a Flesh Construct that is famous for taking huge damage, and a woman who could bury herself. Which didn’t work. There was also a zombie punk samurai thing. My foes went for strategies based on putting markers down on territory, one of which was Squatter’s Rights, which led to a protracted battle between undead and guild members in the middle of the board.

Because Candy and Baby Kade both have “Manipulation,” which makes it a challenge for opponents to attack them, I went for two secretive strategies:

• Deliver a message: Candy has to rock up right next to an enemy leader and use all her actions for the round delivering it a message. Standing in front of an enemy leader doing nothing is … a challenging proposition. But if you have a challenging proposition, why not put it to a blank-eyed Lolita with a bag of poisoned sweets?
• Bodyguard: Baby Kade had to stay alive as long as possible; at turn 4 (with two turns to go) I had to reveal that he was the bodyguard; I got bonus victory points if he was still alive with more than half hits at the end of the game. Baby Kade is fiendish difficult to hit, but he is just a baby …

Ted shambles toward Bethlehem

When the battle started I split my forces, sending Zoraida, Candy and the Sorrow one way towards the Guild’s forces, and Teddy, Baby Kade and Terror Tot the other to take on the Resurrectionists. What’s not to like about a giant, blood-stained teddy bear with massive teeth and two psychotic babies crawling into battle? I soon discovered the power of this gang together – Terror Tot and Baby Kade both have pounce, which means that they get an automatic attack on anyone who moves into their engagement range, and once Teddy gets his hands on you you aren’t leaving the engagement. This little squad of creepy doom caught the Flesh Construct just after he had placed a marker down on a victory point. The Flesh Construct lasted into the 2nd Turn, and my little team came out of that encounter unscathed. Oh Teddy …

Meanwhile I discovered the power of the Voodoo Doll in a tight group. Selecting it to start with was a mistake, because it moved so slowly that Zoraida’s first action was to summon a new one with a spell, causing the old one to die. I could have used those 4 soulstone points on magic of some kind! The newly-summoned Voodoo Doll also got to put a “Sewn Fate” on a Death Marshall, which makes it vulnerable to all other attacks and means it takes damage if it injures the Doll. Zoraida started throwing magic at it to make it shoot its own men (she has a pretty turn in domination magic!) and the presence of the Sorrow meant that the Death Marshall kept taking damage from failed willpower duels. In desperation Big R had this unfortunate Marshall shoot the Voodoo Doll down, killing itself at the same time, and Zoraida just immediately summoned another one, which put a sewn fate on the next closest Marshall. This Marshall did so badly from the presence of the Sorrow that it was reduced to 1 wound simply through badly-timed activations and failed willpower duels, before it had even been attacked. But before it died it did manage to kill a member of its own team (Scales of Justice) at Zoraida’s bidding.

Turn 6 started with Candy in base-to-base contact with Lady Justice, Terror Tot in pounce range, and Teddy ready to munch, but with one other Guild crewmember within missile-fire range. Seamus, the only remaining Resurrectionist, was letting rip with everything he had on Baby Kade – an unfortunately terminal situation for Baby Kade. Initiative was drawn – and Big R won! Lady Justice could act first, and dismember Candy before she could deliver her message! Except … that in the previous round one of my crew (Zoraida?) had cast a spell that induced “Mood Swing” on the other Guild crewmember, allowing me to choose to activate that crewmember in place of any other Guild crew at a time of my choosing. I chose now, so Lady Justice didn’t get to tear Candy apart, the activated crew member failed to kill her, and she delivered her message:

You are going to die

After which all my crew whaled on her, finishing, appropriately, with Teddy delivering the killing blow and swallowing her whole. The other Guild crewmember died during this Turn too, as did Baby Kade, which left me with all but one of my original crew, the Resurrectionists with just their leader, and the Guild completely killed, their leader eaten in one bite by Teddy.

But when we added up the points from our strategies we were all on equal victory points.

I think that’s the definition of a Pyrrhic draw, at least for the Guild. But at least Teddy didn’t go home hungry…

Malifauxcent thoughts

This game was excellent, and the battles and magic so much fun that it was hard to remain focused on strategies – we all just wanted to have at each other and see what happened. The basic mechanic involves drawing a card that resembles a standard playing card (but with very pretty gothy designs), using the number plus an attribute to determine success. The symbols on the cards can act as triggers for additional effects. Every round you also have a hand of 6 cards you can use to “cheat fate,” basically swapping your drawn card for one from your hand to get a better result. Sometimes you get “+” or “-” which are like advantages/disadvantages in D&D 5th Edition (you pull two cards instead of one and choose the best or worst respectively). The abilities and talents of the creatures are all on easily accessible cards, and there is a minimum of tokens and other fiddliness. All you need to do is flip over your card to see what it can do, then do the card draws as required. Soulstones (if you have any) can be used to further cheat these draws.

This mechanism is really fun and, in conjunction with the wide range of sneaky and devious manoeuvres on the cards, generates a really rich and challenging combat environment. Once you’re used to the rules – which are very easy and quick to pick up, and all there on the card – it’s really easy to make decisions and work out what to do, and with just 5-7 crew members it’s not hard to get abreast of your options. Overall it seems like a really well-designed and fun system. There is a role-playing game of Malifaux coming out soon, and I think it could make a really cool system and game world. This game is well worth trying if you get a chance!

The most well-respected methods for reducing carbon emissions seem to be carbon taxes and carbon price mechanisms. I have written before about how I think they will not work to achieve a zero carbon state, based on lessons from the field of public health. Here I want to explore in a little more detail just what we might expect in the long-term from a carbon taxation system.

An illustrative example: Effects of carbon taxes on fishing

Fish are a staple food in Japan, and fishing is a carbon intensive practice because fishing fleets use diesel oil. We can get a rough estimate of how much carbon is required to produce a single piece of fish, and use this to estimate how price would change under a carbon tax. First, consider the total carbon emitted in catching fish: this website puts it at between 1750 and 3300 kg for a ton of fish, with the highest carbon emission amongst farmed fish. The analysis suggests that 1kg of wild-caught frozen salmon will be associated with 1kg of CO2; a carbon footprint of up to 6Kg can be expected for fish that is caught in say Chile, and shipped to the US. Taking 5kg as a conservative estimate of the carbon footprint of a kg of fish, we can see that  for a carbon tax of \$X per ton, \$X/200 is added per kg of fish sold in the super market. So for a price of \$250 per ton, we get \$1.25 per kilogram; for \$2500 per ton, we get \$12.50 per kilogram.

The Coles website tells me that salmon fillets are currently \$30 per kg. A carbon price of \$2500 a ton will increase their cost by approximately 30%.

We can calculate the cost for fresh fish in a supply chain directly, so let’s try this for a typical fresh Tokyo fish, Mackerel. The Seafish.org website has a carbon footprint profiler which indicates that you need to take into account “landed to live weight” and “final processed form to landed weight,” which we can estimate fairly conservatively (though I don’t know the details). This ancient paper (pdf) gives an efficiency of about 3% for shrimp fishing, while this FAO document gives landed weights of between 3 and 84%. Working with Mackerel from that document, let’s assume that only 3% of caught fish is actually edible[1], and make that the “landed to live weight” ratio. The FAO provides a handy guide to “conversion factors” for converting landed fish to actual final processed form, as an annex (pdf) to this guide. Taking the mackerel factor, let’s assume that only 50% of the final fish is eaten, in the form of a fillet. The site then asks us to show how much the fish traveled before and after processing, and by what means. Let’s assume it is landed fresh in Tokyo after a 5 day fishing trip, and that it traveled 40km by truck to the processing plant, then 40 km by van to the shops, and was eaten within a day (pretty standard in Tokyo). Using “Trawling for Herring in the NW Atlantic” as our model fishing method, we get 7.4 tons of CO2 for every ton of final product. So we would need to add X/133 to the per kg price of the fish. For a carbon price of \$250, that’s \$1.90; for \$2500, a \$19.00 impost. This site tells me that Mackerel in Japan costs between 600 and 8000 Yen per kilogram (\$6-80), so a \$2500/ton carbon tax would change this price range to \$25-100 per kg. The Coles website tells me Australians already pay \$20/kg for tinned mackerel – is it very likely that Japanese will baulk at paying \$25 for fresh mackerel? Furthermore, this is for the most inefficient live catch and processing values I can find. If the live catch efficiency goes up to 10%, for example, the impost for those carbon taxes drops to \$0.60 – \$6.

No one on earth is currently considering a \$2500 ton carbon tax. Even \$250 a ton is considered radical, but \$250 a ton will increase the final price of mackerel by \$0.60 – \$1.90 per kg. Does anyone seriously believe that this impost will be sufficient to force the fishing fleet to go carbon-neutral?

What are the long-term impacts of carbon taxes?

I chose fishing as an example because it differs from electricity generation in one simple way: short of returning to sailboats, there is no viable low-carbon alternative to fossil fuels for fishing boats at present. So the fishing industry will have little choice but to absorb the price of a carbon tax, pass it on to consumers, or disappear, unless and until an alternative energy source becomes available. If our goal is to get to a carbon zero economy and still be able to eat fish, a carbon tax is surely not going to work. But there are other aspects of the economy that are entirely vulnerable to a carbon tax, most especially electricity generation and public transport. So how well are carbon taxes predicted to work in these industries?

There does not seem to be a lot of available modeling on the long-term impact of carbon taxes, but those reports that have been published are not promising. For example, this report by the Citizens’ Climate Lobby describes a carbon tax starting at \$10/tonne and increasing to \$250/tonne at \$10/year. They use four different established models to identify total, and industry- and region-wide effects of the carbon tax. Their final estimate of the effect of the carbon tax is a 50% reduction in emissions by 2035 (page 30). After that the gains decline. This report, from the carbon tax center, proposes a system of tax and credits that appears to correspond with a \$113/tonne tax, and would lead to 25% reductions in emissions by 2024 on a 2012 baseline.

350.org says we need to get to 350ppm by the end of the century to avoid catastrophe; we’re currently on 400ppm and increasing at 2ppm per year. If we halve global emissions by 2035, we’ll be above 420ppm, and still increasing.

As another example, my July electricity bill was \$66 for 214kwh of electricity. In Tokyo at the moment this is mostly gas, and would (according to Wikipedia) have released a total of 107 kg of CO2, based on median emissions. At \$250/ton that’s going to increase my electricity bill by about \$25/month. How much electricity use will that discourage? \$25 is a cheap meal out with a few drinks. At \$2500/ton it’s \$250/month – two cheap meals out and two trips to a love hotel. Am I willing to give up two dates a month in order to keep my electricity use unchanged?

I don’t believe that even a \$250/ton carbon tax will be sufficient to force carbon neutrality in electricity generation, and \$2500/ton, while it will make solar and wind competitive and force a fairly rapid switch to renewables, may not lead to much change in other behavior, especially in industries like shipping and trucking where alternatives are expensive and still barely off the drawing board. The Citizens’ Climate Lobby report tells us that in the USA each \$1/ton of carbon tax is a \$.009/gallon increase in petrol prices; \$2500 a ton will increase petrol prices by \$22.5/gallon. Currently in Tokyo gasoline is sold at probably \$2/gallon. Will people completely stop using cars at \$25/gallon? Given that a single journey in Japan can cost \$5 in parking, and a car can travel 35 mpg, i.e. two trips per parking cost, the total cost of those two trips will go from \$14 to \$35 in Tokyo. Is that sufficient to stop recreational use of cars?

These reports make clear that even sizeable taxes of up to \$250/ton are not enough to get where we need to go. The first report, suggesting \$10/year increases in the tax, shows the obvious problem – as the tax grows, the incremental benefit of further increases declines, so going to higher taxes will have smaller and smaller effects. By the time we’re at \$300/ton, a further \$10/year increase will be less than the effect of inflation on prices in many countries. People will stop responding to those taxes by that time. And as I showed in the case of fishing, there will be many industries where this cost can be passed onto consumers with a negligible effect. I routinely buy fish fillets in Tokyo for \$2/fillet, am I seriously going to reduce my carbon footprint if the price of such cheap food doubles?

What we need to bear in mind here is that we don’t want to reduce recreational use of cars by 50% over the next 30 years, or by 90%; realistically, any CO2 emitting form of transport needs to be cut by 99%. These taxes alone are not going to do that.

What do we need to do to achieve carbon zero?

Carbon neutrality will not be achieved by taxes alone. We need additional government interventions to make it happen. Carbon taxes with appropriate transfers to ensure that poor people are compensated for the change are a good start, but they are only a start. We need to go a lot further if we want to achieve these goals. Some policy interventions should include:

• Complete electrification of freight rail: Australia’s rail freight system (indeed all inter-city lines) is still diesel-powered; it should be electrified immediately, so that it can be shifted to a renewable energy source as the taxes bite
• Expansion of passenger and freight rail: Most Australian cities are heavily dependent on road transport, which for the foreseeable future is immune to carbon abatement policies. As much as possible, the transport network needs to be shifted to rail, that can be electrified
• Electrification of all buses: all public buses should be immediately electrified
• Implementation of tollways: all major interstate highways should be shifted to a toll system, with tolls based on both distance travelled and journey speed, and tolls manipulated to ensure long distance travel is always cheaper by train and bus than by car
• Construction of high speed rail: this is never going to be profitable in Australia, so it should be subsidized by government, using carbon tax proceeds, and prices fixed in such a way that it is always competitive with air travel and private road travel
• Minimum price for air travel: Air travel will never be carbon neutral, so it needs to be discouraged or people need to find ways to use their journeys more efficiently (i.e. travel less often and stay longer). A minimum price will encourage this, and should be designed so that electric high speed rail is always cheaper
• Nuclearization of all large ocean-going vessels: if it’s large enough to have a nuclear power source, it should. No freight should be carried on a CO2-emitting ship.
• Reorientation of commercial fishing fleets around batteries and nuclear tankers: I don’t know if this is possible, but fishing needs to be redesigned so it is carbon neutral. If it isn’t yet possible to design battery powered ships, research funds should be dumped into this
• A timetable for the banning of internal combustion engines: Some time in the future, internal combustion engines need to be banned. This timetable should be implemented now. By e.g. 2020, gasoline-using cars should be illegal, so people have 6 years to buy a battery car or convert to CNG; by 2025 or 2030, CNG cars should be illegal. That gives a 15 year time frame to completely electrify the personal transport industry
• Immediate conversion of cars to compressed natural gas: This should be a brief boom industry, as all old cars are converted.
• Lower all speed limits: so that cars travel more efficiently and private travel is less time-efficient than public transport
• Ban all new coal-extraction licenses: No new coal mines should be built anywhere in Australia, and furthermore no new development should be allowed in connection with existing mines. Existing infrastructure bottlenecks to efficient extraction should be seen as a good thing.
• Divestment laws: Investment funds should be required to divest all holdings in carbon-intensive industries on a reasonable but definitive timetable
• Scale-up of electric charging points: Cars should be rechargable anywhere
• Mandatory roof-top solar: for all businesses
• Mandatory grid integration: no power company should be able to refuse a reasonable request to sell power into the grid.
• Mandatory storage in new buildings, and subsidies to convert existing buildings: apartment blocks are not efficient solar collectors, but they could still be built with sufficient storage that they can store some solar power for release onto the grid at night
• Ban all rice and cotton production in the Murray-Darling watershed: water needs to be returned to the river for greening of the river course, because restoring natural wetlands and green areas is essential to improving carbon sequestration
• Huge rewilding and reforestation programs: Carbon sequestration through forestry management is essential, and this project needs to be undertaken immediately, so that it forms a key part of future carbon reduction strategies. It can be conducted in such a way as to support and restore biodiversity
• Huge research grants on storage and renewable energy: We need to get to the point where electric trucks and ocean-going boats are a possibility within 20 years. This will need research. We should be doing it

And finally, I think that climate change denial should be illegal outside of scientific journals – if people want to claim it’s not happening they should be required to present peer-reviewed scientific evidence. Funding climate change denial should be a criminal act. The government should further refuse to offer contracts to organizations that have hosted denialists or funded denialists in e.g. the last 10 years. These people need to be driven out of public life and should have no influence on public debate. It is absolutely ludicrous that after three of the hottest months on record (April, May and June), the government’s business advisor is publicly claiming that a period of major global cooling is imminent. That dude should be unemployable, and preferably in stocks[2].

A lot of these programs will require major government subsidies, transfers and loans, and huge government intervention across a range of marketplaces. We need to stop acting as if the worst consequence of responding to the climate crisis is government intervention in markets, and start recognizing that it is the minimum requirement to stave off a civilization-level disaster. It’s huge government intervention now, or civilization collapse later.

So go looking back through history and ask yourself – has any civilization collapse ever been preventable through a small tax that raised the price of fish by 10%? I think you’ll find the answer is no. The emergency is coming, and we need to act as if it’s an emergency, not a minor market failure.

fn1: For farmed fish, this number should be near 100%, obviously.

fn2: This is clearly a rhetorical point

Eerily romantic

I have recently been exploring the shadowy and terrifying world of the Neath, in a fascinating and quite engaging game called Sunless Sea. This game is set in a location called Fallen London, an scattering of island archipelagos on a vast underground sea, which was formed at the conclusion of a previous game from the same company, Fallen London. This sunless world is an ocean in a deep cavern, full of horrors and strange stories. The game is viewed from above, essentially on a map, and you play the captain of a steamship who is plying the Neath (the name of the underground ocean) trying to become famous or rich or both. Based in the town of London, you travel between islands trading, picking up stories, fighting pirates, and doing the bidding of mysterious powers. Travel across the darkened seas is fraught with risks, however: in addition to the risk of running out of food and fuel and having to eat your crew, there are also pirates, monsters, and the ever-present growing fear of the darkness. Journeys have to be carefully spaced to ensure you can return to London before the fear mounts and your crew mutiny on you, or the nightmares consume you. There are also mysteries to unravel, and stories involving different organizations and kingdoms.

Strange shops in a strange world

The game is viewed from above and there are no animations for battles or encounters, just text-based interaction as shown in the picture above. However, despite the lack of animations the graphics are very stylish and engaging, and very carefully build the sense of terror and weirdness that pervades the game. Drawn a little like a comic, but with a grim wash, and with a writing style that is a mixture of dark humour, Victorian prose, and elegant horror, the narrative really gets you involved in the world. It’s also quite challenging, and if you play it the way it is intended, death will be a common event. As the game progresses and the stakes get higher, the struggle with terror also becomes quite consuming, as you try to balance your need to travel the dark reaches of the farthest-flung islands with the compulsion to keep your terror from overwhelming you.

The game has a few flaws, however. First of all it has quite a sedate pace, so if you’re the kind of gamer who needs edge-of-the-seat energetic game play, it will probably bore you. Also, sometimes the mission details are hard to access, and the game doesn’t tell you when you have completed a task (in some cases), so you can feel lost at sea (literally!) when in fact you have met the conditions of a quest. It is also difficult to piece everything together into a coherent story, so sometimes it feels like the game just intends for you to grind, grind, grind – I still don’t have a sense of a unifying story or theme to the game, and I’m not sure if it will hold my attention if it does not have a theme. It is also quite hard to make money, though I have begun too, and the rules aren’t very deeply explained, so you spend a lot of time making pointless mistakes at first, and I suspect some players have given up early on because of this. However, once you’ve died a few times and googled a few things, the peculiarities of the world and its systems will begin to make sense.

With that in mind, I thought I’d produce here a list of tips for how to play, based on what I have learnt so far.

• Always have good stocks of fuel: at first you will only be making small amounts of money, and may find it difficult to purchase things like weaponry; don’t give in to the temptation to spend your cash on a bigger gun when you don’t have much spare, because if you don’t have much fuel, you will find yourself unable to travel to make more money. Always retain enough fuel to at least be able to do a tomb-colonist run, so you can replenish fuel on the return. And always ensure you have enough fuel for the return journey when you head away from London – it is expensive everywhere else (except Palmerston) and if you run out on the high seas you are in big, big trouble
• Keep your terror down: It is extremely hard to get your terror down from high levels, and/or expensive, so keep your terror down. The main way to do this is to sail through lighted areas, or close to shore. Sure, the pirate raiding requires that you sometimes sail away from the buoys, but you need to make sure that when you travel you stay in the light as much as possible. Especially on long missions, or missions which are going to themselves raise your terror (and many do!) you don’t need to also be burdened with terror built up through frivolous course-tracking
• Take the blind bruiser’s gift: the only consequence is that later he will ask you to deliver some souls to a far-away place, and you will make your first big cash of the game when you do that
• Build up admiralty’s favour: it gets you more lucrative and interesting missions, and access to cheaper repairs
• Keep visiting Hunter’s Keep: Hunter’s Keep is very close to London, and spending time with the sisters will get your terror down. It may seem boring to drop in on a place where you keep having the same conversations, but that soon changes. Hunter’s keep is one of the first stories to reach its resolution, and if you play your cards right you can emerge from the ruins of the story a lot wealthier than you were at the start
• Watch your nightmares: When you return to London with terror>50 points it automatically resets to 50 (which, btw, is not good!) but your “nightmare strength” increases. Nightmares on the high seas can lead to trouble, including higher terror and ultimately mutiny. It is extremely hard to get your nightmare strength down, but there is one surefire way: travel to the Chapel of Lights north-east-east of London, and visit the well; you can make a sacrifice here and though you incur a wound, you lose nightmares. Do this twice and you can get rid of almost all your nightmares (though having 2 wounds is very risky)
• Go bat-hunting: bats are easy to kill, and if you throw their corpses overboard you lose a few points of terror. This is the only relatively reliable way I have found to get terror down a lot, though it is not cheap. Basically if you hang around a buoy near Venderbright (or the island of Tanah-Chook, near Venderbright) you will be regularly attacked by bats, but will gain no terror from your location. If you kill 10 or 20 swarms of bats you will get your terror down by 15-30 points, which is really useful. It will cost you in fuel and supplies, though you can recoup the supplies from bat-meat, so make sure you have spare money and fuel before you do this. I think terror affects your abilities, so it’s good to keep it low
• Torpedos are useful: keep a few in reserve. I was ambushed by a Lifeberg on my way back from the Avid Horizon, and in a moment of desperation I unleashed some, that did it a lot of damage. I took some hull damage but it kept me alive. They cost a lot, but they can be fired early in the battle and do a lot of damage. Combat in Sunless Sea works by increasing illumination until you can see your enemy enough to shoot them, but for the bigger enemies (like Clay Pirates and Lifebergs) you need illumination 100 to get in a really good salvo against them. Getting to illumination 100 without getting sunk is extremely difficult, but torpedos do damage similar to a powerful gun salvo at illumination 50, so if you get ambushed by something much tougher than you they can be a handy way to get out of trouble
• Keep visiting the old dude in Venderbright: At some point in Venderbright you will get the option to talk to the head of the tomb-colonists, who gives you a mission to explore and find the colours from 8 or so pages of a book. I found two of these colours but the game didn’t tell me I had them, and it took me ages to visit the old dude again. When I did I got an item worth 500 echoes as a reward. So my advice is, once this mission has been unlocked, visit the guy regularly because you can’t be sure you have achieved one of the goals, and the money is worth it. A lot of people say that trips to Venderbright aren’t worth it, but I don’t agree. Not only can you make a bit of money selling news and colonists, but when you explore you can pick up quite valuable artifacts, and as a stop on the way to places further afield, it’s a good way to make a bit of money and get your terror down a bit. Plus some of the story options (the Bandaged Poissonier, Jonah’s revenge, the old dude with the book) can be valuable for you later. So I recommend continuing to visit here.
• Always go coral-picking at Port Cecil: a single scintillack is worth 70 echoes.
• Always collect port reports: they can fund your trips, and the admiralty will pay for them no matter how many times you give them
• Grab stray chances: someone left a coffin on the docks for me once. I took it, and it opened up a whole new island for me. Take any chance you are given!
• Avoid fights with bigger ships: sure, you can defeat the clay pirates, but unless your mirrors stat is very high you will take hull damage, which will cost about 50 echoes to fix, and all you will get in exchange is a few supplies or a bolt of parabola-silk or something – the maximum profit will be 20 echoes. You can make 20 echoes from a steam pinnace with zero risk. Avoid them.
• Use the alt-f4 cheat: I’m playing on a mac, I don’t know how to do alt-f4 but I can still do control-command-escape or whatever, and kill the game when I die. Once you are a long way into the game, dying is not such a great idea, so be ready to do this – when you die, kill the game or load before you save, so that you can restart from your last port of call. Otherwise, you have a long upward climb ahead of you …

I think that’s it. I’m slowly gathering stories and trying to find out where the game goes, and I’m not sure if I will finish it (or if it can be “finished”, per se) but I’m enjoying the experience of this new world. I think it would also make a disturbing and evocative role-playing world. If you’re into cthulhu-esque horror and don’t need fancy graphics to make your games fun, I strongly suggest this game. It can be a bit irritating at first, but once you get up and running it’s a really rich and pleasant experience!

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